How To Use CPT Code 38745

CPT 38745 describes the complete removal of all lymph nodes in the armpit area, including both superficial tissues and those buried deep beneath layers of muscle. 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 38745?

CPT 38745 can be used to describe the surgical procedure in which a provider removes all of the lymph nodes in the armpit area below the axillary vein. This includes both superficial tissues and those buried deep beneath layers of muscle. The removal of axillary lymph nodes is commonly performed for cancer in the breast or chest.

2. Official Description

The official description of CPT code 38745 is: ‘Axillary lymphadenectomy; complete.’

3. Procedure

1. The provider prepares the patient for the procedure and administers anesthesia.
2. A diagonal incision is made in the armpit area to access the lymph nodes.
3. The provider carefully removes all of the lymph nodes in the armpit area below the axillary vein, including both superficial tissues and those buried deep beneath layers of muscle.
4. If there are any other involved or nearby tissues, the provider may also remove them.
5. The provider ensures hemostasis to stop any bleeding.
6. The incision is closed in layers, and a drain may be placed to facilitate healing.

4. Qualifying circumstances

CPT 38745 is typically performed for patients with extensive cancer of the breast or chest wall. It involves the complete removal of all lymph nodes in the armpit area below the axillary vein. The procedure is performed by a qualified provider who has the necessary expertise in lymph node dissection.

5. When to use CPT code 38745

CPT code 38745 should be used when a provider performs a complete axillary lymphadenectomy, removing all lymph nodes in the armpit area below the axillary vein. It is important to ensure that the procedure is medically necessary and appropriate for the patient’s condition.

6. Documentation requirements

To support a claim for CPT 38745, the provider must document the following information:

• Indication for the procedure, such as extensive cancer of the breast or chest wall
• Details of the procedure performed, including the complete removal of all lymph nodes in the armpit area below the axillary vein
• Any additional tissues removed during the procedure
• Confirmation of hemostasis
• Description of the closure technique used
• Placement of a drain, if applicable

7. Billing guidelines

When billing for CPT 38745, ensure that the procedure meets the criteria for complete axillary lymphadenectomy. It is important to review the documentation and ensure that all necessary information is included to support the claim. CPT code 38745 may bundle into other procedures for the treatment of extensive cancer of the breast or chest wall, so it is important to review the code guidelines and any applicable bundling rules.

8. Historical information

CPT 38745 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 a complete axillary lymphadenectomy for a patient with extensive breast cancer.
2. A patient with chest wall cancer undergoes a complete axillary lymphadenectomy to remove all lymph nodes in the armpit area.
3. A provider performs a complete axillary lymphadenectomy for a patient with metastatic cancer in the axillary lymph nodes.
4. A patient with recurrent breast cancer undergoes a complete axillary lymphadenectomy to remove all lymph nodes in the armpit area.
5. A provider performs a complete axillary lymphadenectomy for a patient with extensive chest wall sarcoma.
6. A patient with locally advanced breast cancer undergoes a complete axillary lymphadenectomy to remove all lymph nodes in the armpit area.
7. A provider performs a complete axillary lymphadenectomy for a patient with metastatic melanoma in the axillary lymph nodes.
8. A patient with recurrent chest wall cancer undergoes a complete axillary lymphadenectomy to remove all lymph nodes in the armpit area.
9. A provider performs a complete axillary lymphadenectomy for a patient with extensive axillary lymph node involvement from an unknown primary tumor.
10. A patient with locally advanced chest wall cancer undergoes a complete axillary lymphadenectomy to remove all lymph nodes in the armpit area.