# 38570 vs 38571 Lap lymph node excision.



## natashalage (Dec 18, 2020)

Hello,

I am looking for help to understand when we code 38570 vs 38571.

38570-Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple

38571-Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy

I read the descriptions of CPT and understood that sentinel nodes/Bx will be coded under 38570 because it’s a sample, first time learning about the disease. Sentinel nodes can be in different areas of the body. What I don’t understand is then MD is using 2 words ‘*sentinel pelvic nodes are excised*” Did he excise sentinel 38570 or pelvic nodes 38571? I am lost. I have 2 examples below for your review and will greatly appreciate your help on these 2 codes and *what to look for in the Op note*.
_*Thank you very much in advance.*_

MD performs Lap hysterectomy with:

Case 1… with *sentinel* lymph node mapping +38900 with *pelvic l*ymph node biopsies. “We discussed a minimally invasive surgical staging procedure with sentinel lymph node mapping. ‘as a candidate sentinel lymph node, and therefore we excised both these as our biopsy specimens”
_Path: _Left &Right _*obturator sentinel* lymph node_ + L&R _external *iliac sentine*l lymph node_. Number of* sentinel *nodes examined: 5.
I would code it as sentinel node resection only- 38570. Is that right?

Case 2. Lap Uterus+ bilateral *pelvic sentinel* lymph node dissection. ‘We took the lymph nodes that were both at the bifurcation of the external iliac vein. The obturator nerves were identified bilaterally just underlying the sentinel nodes. Specimens: bilateral sentinel pelvic lymph nodes.
Path: Left pelvic sentinel lymph node, biopsy: No tumor (0/1).
C. Right pelvic sentinel lymph node, biopsy: No tumor (0/1).
Is that sentinel nodes 38570 or pelvic 38571? I am struggling with it all afternoon.


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## csperoni (Dec 18, 2020)

Basically, whenever they are doing the sentinel mapping, 38570 is the correct code.  Before that procedure was available, often all pelvic nodes that were identified were removed, which would be 38571 (or 38572 when para-aortic were sampled as well).  
I have seen no sentinel nodes identified,  in which case the surgeon will sometimes do complete pelvic nodes (38571) or sometimes just "suspicious" nodes (38570.)

For both of your cases above, 38570 would be appropriate, along with 38900-LT and 38900-RT for the sentinel identification.  

Here is a good diagram of the pelvic nodes.   https://training.seer.cancer.gov/ovarian/anatomy/lymph-nodes.html
In your case #1, 5 nodes were removed and case #2, 2 nodes.  You can see there are many more pelvic nodes than that.  

The procedure of being able to identify sentinel nodes intra-operatively definitely is a benefit to the patient.  Recovery can be easier and helps avoid long term potential complications of removing more/all nodes.  

I hope this helps better explain it for you.  Trust me, I know gynonc coding can be challenging.  It can be very beneficial to develop a collaborative relationship with the clinicians.  Once they realize that the better you understand, the more accurate their coding is, they are typically very helpful.  It's a 2 way street.


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## natashalage (Dec 20, 2020)

Dear Christine, Thank you for responding to my post. I also greatly appreciate any input from other professionals. Thank you.
After reviewing the link, doing more research, I drew preliminary conclusions for the review. 
1. In now days, MD do a *sentinel node (SN)* dissection, biopsies to determine if cancer has spread because SN is/are the closest nodes to a tumor.  It's the 1st step after tumor is detected. CPT 38900 for mapping and 38570 for excision on sentinel node/s or biopsy. It could be 1 or many nodes. Px can be done prior or during a hysterectomy etc surgery.
2. What to look for in Op note when coding 38500? Look for a key word '*sentinel node'* like '_excision of sentinel pelvic nodes', 'biopsy of sentinel pelvic nodes'
3. _SN Px is  done to avoid lymphadenectomy but once Path determines that cancer metastasized to 'sentinel pelvic node/s, the surgery is scheduled to do a Total pelvic lymphadenectomy - 38571 or 38572 laparoscopic.
4. What to look for in OP note when coding 38571 or 38572? Should be obvious: listing the names of pelvic nodes that are being excised, should not say Sentinel! Work with surgeon on clarification. Great advice, Christine. I should find courage to ask surgeon a question and build collaborative relationship with them.
Any comments are greatly appreciated!


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## csperoni (Dec 21, 2020)

1) Most surgeons, yes.  It's typically done for patients with endometrial cancer or cervical cancer, which is often a known malignancy prior to the surgery.  I don't recall every seeing it done for ovarian cancer patients, where 99.8% of the time, it is not a known malignancy at the time of surgery.  Typically 2-4 nodes.  Could be a few more, but certainly not 20.  Usually will remove any node that the dye lights up as sentinel, or if any visible nodes look suspicious.  
2) I'll assume that was a typo & you meant 38900.  So what constitutes 38900?  The official description is "Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)"  My surgeons will dictate in the op note something like "ICG dye injected in the cervix at 3 and 9 o’clock positions circumferentially at two different depths 1 cc injection each." and further down "The Firefly optics of the DaVinci system were used to identify the sentinel nodes in the pelvis bilaterally. There were noted to be bilateral external iliac sentinel lymph nodes, which were placed in the pelvis. No enlarged or concerning lymph nodes seen in the pelvis bilaterally. There were no sentinel nodes in the para-aortic node chains."
3) No medical school here, but my understanding is that the lymph nodes are removed in order to stage the cancer.  My docs have never gone back and done a total pelvic lymphadenectomy if the sentinel nodes were positive.  They are looking to see if there is any spread, to determine the best treatment course (various chemo options vs radiation vs chemo/radiation sandwich, etc).  They MIGHT do another lymph node (and/or debulking) procedure after chemo/radiation if PET shows active areas.
4) Basically, if the op note states "sentinel" they are not doing a total pelvic lymphadenectomy.  If they are, op note should state so.  If for example it just said "pelvic lymphadenectomy" without the words total or sentinel, I would read the body of the op note more carefully and check how many nodes on pathology.  And educate the provider for clearer documentation.


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