You can use CPT 38525 for the surgical removal of deep axillary lymph node(s) with open incision for biopsy.
1. What Is CPT Code 38525?
This code covers the surgical removal of lymph nodes in the patient’s deep axilla. The procedure is performed through an open incision, and the lymph nodes can be sent for analysis to a laboratory.
This procedure investigates upper torso and breast tumors or treats them.
The CPT book describes CPT 38525 as follows: “Biopsy or excision of lymph node(s); open, deep axillary node(s).”
This procedure begins with positioning the patient on the operating table in the supine position after they have been anesthetized and prepped.
Next, a roll is placed under the patient’s shoulder for easier access to the axilla. Then, they incise the patient’s skin down into the deep axillary tissues until they reach the target node(s).
They then excise the targeted node(s) before reapproximating the skin and axillary tissues in layers.
Finally, they drain the deeper part of the surgical wound and may leave it there sutured to the skin, so it continues to drain fluids from the wound while it heals.
4. How To Use CPT 38525?
Use CPT code 38525 only once, regardless of the number of nodes biopsied from the axilla with an open excision.
Append modifier 50 to 38525 if the procedure was performed bilaterally.
This code is in the merit-based incentive payment system.