How To Use CPT Code 38555

CPT 38555 describes the excision of a cystic hygroma from deep in the armpit or neck, involving deep neurovascular dissection. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 38555?

CPT 38555 can be used to describe the surgical excision of a cystic hygroma located deep in the armpit or neck. This procedure involves the removal of the cyst while also performing deep dissection to preserve critical nerves and blood vessels in the area.

2. Official Description

The official description of CPT code 38555 is: ‘Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection.’

3. Procedure

1. The patient is prepped and anesthetized, and the provider adjusts the patient’s neck to improve access to the target area.
2. For an axillary hygroma, the patient may be turned in a lateral position or the shoulder may be padded to enhance exposure.
3. The provider uses a scalpel to dissect the tissue overlying the cyst or cysts, which are deeply seated or involved with critical nerves and blood vessels.
4. The provider excises the cyst completely if possible, but in some cases, it may be impossible to remove all parts of the hygroma.
5. Remaining parts of the hygroma may be cauterized by the provider.
6. The provider reapproximates the tissues in layers and closes the wound, potentially placing a drain to facilitate healing.

4. Qualifying circumstances

CPT 38555 is used for the excision of cystic hygromas that are deeply involved with critical nerves and blood vessels in the axillary or cervical region. These cysts are typically congenital and may be found in the neck or armpit. The decision to remove all or part of the hygroma depends on the involvement with underlying structures and the provider’s judgment.

5. When to use CPT code 38555

CPT code 38555 should be used when a provider performs the excision of a cystic hygroma with deep neurovascular dissection in the axillary or cervical region. It is important to note that this code should not be reported bilaterally, and if reexcision is necessary, it should be coded separately.

6. Documentation requirements

To support a claim for CPT 38555, the provider must document the following information:

• Patient’s diagnosis and the need for excision of the cystic hygroma
• Details of the deep neurovascular dissection performed
• Date of the procedure
• Specific location of the cystic hygroma (axillary or cervical)
• Extent of the excision and any remaining parts of the hygroma
• Closure technique used
• Use of any drains and their placement

7. Billing guidelines

When billing for CPT 38555, ensure that the excision of the cystic hygroma involves deep neurovascular dissection in the axillary or cervical region. It is important to note that this code should not be reported bilaterally, and if reexcision is necessary, it should be coded separately. Modifier 22 may be appropriate if the provider performs extra work due to scarring or alteration in anatomy.

8. Historical information

CPT 38555 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performs the excision of a cystic hygroma located deep in the armpit, preserving critical nerves and blood vessels in the area.
2. A patient undergoes surgical removal of a cystic hygroma in the neck, with deep neurovascular dissection performed by the provider.
3. A provider excises a cystic hygroma in the axillary region, carefully dissecting the tissue to preserve critical structures.
4. A patient with a cystic hygroma in the cervical area undergoes surgical excision, involving deep neurovascular dissection by the provider.
5. A provider performs the excision of a cystic hygroma in the axillary region, ensuring the preservation of critical nerves and blood vessels.
6. A patient undergoes surgical removal of a cystic hygroma in the neck, with deep dissection performed by the provider to preserve underlying structures.
7. A provider excises a cystic hygroma in the axillary area, performing deep neurovascular dissection to preserve critical nerves and blood vessels.
8. A patient with a cystic hygroma in the cervical region undergoes surgical excision, involving deep dissection by the provider to preserve underlying structures.
9. A provider performs the excision of a cystic hygroma located deep in the armpit, ensuring the preservation of critical nerves and blood vessels.
10. A patient undergoes surgical removal of a cystic hygroma in the neck, with deep neurovascular dissection performed by the provider to preserve underlying structures.