How To Use CPT Code 38525

CPT 38525 refers to the open biopsy or excision of deep axillary lymph node(s), a surgical procedure performed to investigate or treat tumors in the breast or upper torso. This article will cover the description, procedure, qualifying circumstances, billing guidelines, documentation requirements, historical information, similar codes, and examples of CPT 38525.

1. What is CPT 38525?

CPT 38525 is a medical code used to describe the open biopsy or excision of one or more deep axillary lymph node(s). This surgical procedure is performed to investigate or treat tumors in the breast or upper torso. The lymph nodes are removed through an open incision and may be sent to a laboratory for analysis.

2. 38525 CPT code description

The official description of CPT code 38525 is: “Biopsy or excision of lymph node(s); open, deep axillary node(s)”.

3. Procedure

The 38525 procedure involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The patient is positioned supine on the operating table, with a roll placed under the shoulder to improve access to the axilla.
3. The provider uses a scalpel to incise the skin and dissect down to the deep axillary tissues containing the target node(s).
4. The lymph node(s) are excised.
5. The axillary tissues and skin are reapproximated in layers.
6. A drain may be left in the deeper part of the wound and sutured to the skin to drain blood or other fluids while the wound heals.

4. Qualifying circumstances

Patients eligible to receive CPT code 38525 services are those who have been diagnosed with or are suspected of having tumors in the breast or upper torso. The lymph nodes in the deep axilla are targeted for biopsy or excision due to their potential involvement in the disease process. The procedure may be performed as part of a diagnostic workup or as a treatment for the identified condition.

5. When to use CPT code 38525

It is appropriate to bill the 38525 CPT code when the provider performs an open biopsy or excision of one or more deep axillary lymph node(s) as part of the investigation or treatment of tumors in the breast or upper torso. The code may only be used once, regardless of the number of nodes biopsied in the same area. If the procedure is performed bilaterally, add modifier 50.

6. Documentation requirements

To support a claim for CPT 38525, the following information should be documented:

• Patient’s medical history and physical examination findings
• Indication for the procedure, including the suspected or confirmed diagnosis
• Details of the surgical procedure, including the number of lymph nodes biopsied or excised
• Postoperative care instructions and follow-up plan
• Pathology report, if applicable

7. Billing guidelines

When billing for CPT code 38525, keep in mind the following guidelines and rules:

• The code may only be used once, regardless of the number of nodes biopsied in the same area.
• If the procedure is performed bilaterally, add modifier 50.
• Ensure that all required documentation is included in the patient’s medical record to support the claim.

8. Historical information

CPT 38525 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2001, with the previous descriptor being “Biopsy or excision of lymph node(s); deep axillary node(s)”.

9. Similar codes to CPT 38525

Five similar codes to CPT 38525 and how they differentiate from CPT 38525 are:

1. CPT 38500 – Involves the open biopsy or excision of superficial lymph node(s), not deep axillary node(s).
2. CPT 38510 – Refers to the open biopsy or excision of cervical lymph node(s), not deep axillary node(s).
3. CPT 38520 – Pertains to the open biopsy or excision of deep cervical lymph node(s), not deep axillary node(s).
4. CPT 38530 – Involves the open biopsy or excision of inguinal lymph node(s), not deep axillary node(s).
5. CPT 38542 – Refers to the open biopsy or excision of deep inguinal lymph node(s), not deep axillary node(s).

10. Examples

Here are 10 detailed examples of CPT code 38525 procedures:

1. A patient with breast cancer undergoes an open excision of deep axillary lymph node(s) to determine the extent of the disease.
2. A patient with a suspicious mass in the upper torso undergoes an open biopsy of deep axillary lymph node(s) for diagnostic purposes.
3. A patient with recurrent breast cancer undergoes an open excision of multiple deep axillary lymph nodes as part of their treatment plan.
4. A patient with a history of melanoma undergoes an open biopsy of deep axillary lymph node(s) to assess for metastatic disease.
5. A patient with a malignant tumor in the upper arm undergoes an open excision of deep axillary lymph node(s) to determine the extent of the disease.
6. A patient with a suspicious mass in the chest wall undergoes an open biopsy of deep axillary lymph node(s) for diagnostic purposes.
7. A patient with a history of breast cancer undergoes an open excision of deep axillary lymph node(s) as part of their surveillance plan.
8. A patient with a malignant tumor in the shoulder undergoes an open excision of deep axillary lymph node(s) to assess for metastatic disease.
9. A patient with a suspicious mass in the axilla undergoes an open biopsy of deep axillary lymph node(s) for diagnostic purposes.
10. A patient with a history of lymphoma undergoes an open excision of deep axillary lymph node(s) to assess for disease recurrence.