How To Use CPT Code 38571

CPT 38571 describes the laparoscopic procedure of bilateral total pelvic lymphadenectomy. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 38571?

CPT 38571 is used to describe a laparoscopic surgical procedure in which the provider removes all lymph nodes on both sides of the pelvis. This procedure is performed to remove any diseased lymph nodes and prevent the spread of cancer to other areas of the body.

2. Official Description

The official description of CPT code 38571 is: ‘Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy.’

3. Procedure

1. The provider begins by making small incisions in the abdomen and inserting a camera, called a laparoscope, to view the lymph nodes.
2. Once inside the abdomen, the provider removes any adhesions and uses suction to clear the area of blood and clots for better visibility.
3. The provider then explores the abdomen and excises all lymph nodes in the pelvis.
4. In cases of extensive metastatic cancer, the provider may need to remove additional lymph nodes and tissues in the pelvis and abdomen.
5. After ensuring hemostasis, the provider closes the small incisions with sutures.

4. Qualifying circumstances

CPT 38571 is performed on patients with cancer or other conditions that require the removal of lymph nodes in the pelvis. The procedure is typically done by a laparoscopic surgeon and involves the complete removal of lymph nodes on both sides of the pelvis.

5. When to use CPT code 38571

CPT code 38571 should be used when a laparoscopic surgeon performs a bilateral total pelvic lymphadenectomy. It is important to note that this code should not be reported if the procedure is already included in another laparoscopic procedure. Modifier 58 may be appended to indicate that the procedure was planned or staged.

6. Documentation requirements

To support a claim for CPT 38571, the provider must document the following information:

• Patient’s diagnosis and the need for lymphadenectomy
• Date of the procedure
• Details of the procedure, including the use of laparoscopic techniques
• Extent of lymph node removal
• Any additional procedures performed during the same session
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 38571, ensure that the procedure is performed by a laparoscopic surgeon and includes the complete removal of lymph nodes in the pelvis. This code should not be reported if it is already included in another procedure. Modifier 58 may be used to indicate a planned or staged procedure.

8. Historical information

CPT 38571 was added to the Current Procedural Terminology system on January 1, 2000. There have been no updates to the code since its addition.

9. Examples

1. A laparoscopic surgeon performs a bilateral total pelvic lymphadenectomy on a patient with ovarian cancer.
2. A patient with testicular cancer undergoes a laparoscopic procedure for the removal of lymph nodes in the pelvis.
3. A laparoscopic surgeon performs a bilateral total pelvic lymphadenectomy on a patient with endometrial cancer.
4. A patient with bladder cancer undergoes a laparoscopic procedure to remove lymph nodes in the pelvis.
5. A laparoscopic surgeon performs a bilateral total pelvic lymphadenectomy on a patient with cervical cancer.
6. A patient with prostate cancer undergoes a laparoscopic procedure for the removal of lymph nodes in the pelvis.
7. A laparoscopic surgeon performs a bilateral total pelvic lymphadenectomy on a patient with colorectal cancer.
8. A patient with uterine cancer undergoes a laparoscopic procedure to remove lymph nodes in the pelvis.
9. A laparoscopic surgeon performs a bilateral total pelvic lymphadenectomy on a patient with vulvar cancer.
10. A patient with penile cancer undergoes a laparoscopic procedure for the removal of lymph nodes in the pelvis.