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BETA v.3.0

2025 CPT code 38531

Open biopsy or excision of one or more inguinofemoral lymph nodes.

Report only one unit of 38531 per operative area, regardless of the number of nodes removed.Use modifier 50 for bilateral procedures and modifier 59 when performing biopsies in separate areas.

Modifiers can be applied to 38531. Modifier 50 is used for bilateral procedures, and modifier 59 is used to indicate a distinct procedural service.

Medical necessity is established by the presence of signs, symptoms, or other clinical findings that suggest the need for lymph node biopsy or excision to diagnose or stage a disease process.

The physician is responsible for preparing the patient, administering anesthesia, making the incision, dissecting the tissue, excising the lymph nodes, suturing, placing drains if necessary, and sending the specimen to pathology.They must also consider the use of sentinel node biopsy techniques.

IMPORTANT:For injection of a radioactive tracer for sentinel node identification, use 38792. For intraoperative mapping of sentinel lymph nodes with a non-radioactive dye, use 38900. For bilateral procedures, append modifier 50. For distinct procedural service, use modifier 59.

In simple words: The doctor makes a cut in the groin area to remove some lymph nodes to check for disease.Sometimes a special dye is used to find the most important lymph node to remove first.

This code describes a procedure where the provider makes an open incision in the inguinofemoral region (groin and upper thigh) to access and remove all or part of one or more lymph nodes for diagnostic purposes. The procedure involves skin incision, tissue dissection, lymph node excision, suturing, and possible drain placement.A sentinel node biopsy technique may be used, involving injection of dye to identify the first node receiving drainage from the affected area. This helps determine the extent of disease spread.

Example 1: A patient presents with a suspicious mass in the groin area. An open biopsy of the inguinofemoral lymph nodes is performed to determine if the mass has spread to the lymphatic system., A patient with melanoma undergoes a sentinel lymph node biopsy of the inguinofemoral nodes to stage the cancer and determine if it has metastasized., A patient has enlarged inguinofemoral lymph nodes.A biopsy is performed to diagnose the cause of the enlargement, such as infection or lymphoma.

Documentation should include details of the incision, the number and location of lymph nodes biopsied or excised, the use of any dyes or tracers, the diagnosis necessitating the procedure, and any complications encountered.

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