2025 CPT code 38500
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Hemic and Lymphatic Systems Surgery Feed
Open excision or biopsy of superficial lymph node(s).
Modifiers 50 and 59 are applicable, as described above. Other modifiers might apply depending on circumstances.
Medical necessity for this procedure is established based on the presence of a palpable mass, persistent inflammation, signs of infection, or suspicion of malignancy in a superficial lymph node.The procedure is necessary to obtain adequate tissue for diagnostic evaluation and to rule out serious underlying pathologies.
The physician is responsible for pre-operative preparation, anesthesia administration (if applicable), surgical incision, lymph node identification and removal, tissue approximation, wound closure, and post-operative care.The physician also oversees specimen collection and submission for pathological analysis and interpretation of the results.
In simple words: The doctor makes an open cut to remove or take a sample of a lymph node near the skin's surface. This is usually done to check for infection or disease.
This CPT code encompasses the open surgical excision or biopsy of superficial lymph nodes.The procedure involves surgical incision over the affected lymph node(s), careful removal of the node(s) either wholly or partially using a scalpel, meticulous approximation and closure of the incisional site. When performed as a biopsy, multiple tissue samples are collected and submitted for pathological examination to ascertain the presence of infection or disease.This procedure is distinct from needle biopsy, utilizing a more extensive sampling technique.
Example 1: A patient presents with a palpable, enlarged superficial inguinal lymph node. The physician performs an open excisional biopsy of the node to determine the etiology of lymphadenopathy.The pathology report reveals metastatic squamous cell carcinoma., A patient with a history of breast cancer undergoes a sentinel lymph node biopsy. The procedure involves open excision of the sentinel lymph node to assess for micrometastases. The pathology report is negative., A patient presents with a persistently draining, infected superficial lymph node in the neck region. The physician performs an open excisional biopsy, sends the sample for culture and sensitivity, and initiates appropriate antibiotic therapy.
** This code is used for superficial lymph nodes, and deep nodes will require different coding.Always ensure correct anatomical location is documented for accurate coding.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Payment Status: Active
- Specialties:General Surgery, Surgical Oncology, Otolaryngology
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)