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BETA v.3.0

2025 CPT code 38564

Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)

This code should not be reported for lymphadenectomy performed as part of a primary tumor resection. Modifier 58 may be appropriate if the staging procedure occurs during the global period of a previous procedure.

Modifiers may be applicable.For example, modifier 58 is used if the procedure is staged.

Medical necessity must be supported by documentation confirming the need for surgical staging of a malignancy involving retroperitoneal lymph nodes. Imaging studies may also be necessary to support the need for surgical staging.

The physician performs a limited lymphadenectomy of the retroperitoneal lymph nodes to stage cancer.This involves making an incision, exploring the abdomen, excising lymph nodes, and sending them for pathological analysis.

In simple words: The doctor removes lymph nodes from behind the abdominal lining, near the major artery (aorta) and spleen, to determine if and how far cancer has spread. This helps decide the stage of cancer and what treatment is needed.

This procedure involves the excision of lymph nodes from the retroperitoneal area for cancer staging.The surgeon makes an incision and explores the abdomen. Lymph nodes near the spleen and aorta are removed and sent for pathological examination to determine the presence and extent of metastatic cancer.This information is crucial for staging the cancer and planning treatment.

Example 1: A patient with suspected pancreatic cancer undergoes this procedure to determine whether the cancer has spread to nearby lymph nodes., A patient with lymphoma undergoes this procedure to assess the extent of lymph node involvement and help guide treatment decisions., A patient with testicular cancer has this procedure to ascertain the stage of the cancer by evaluating the spread to retroperitoneal lymph nodes.

Documentation should include operative report detailing the procedure, the specific lymph nodes removed, and findings. Pathology report confirming the diagnosis, including the number of nodes positive for malignancy, is essential for staging.

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