# 38500



## ksrkelly7 (Jan 13, 2016)

Hi there.  I need some help with this OP report.  Doc wants to bill 38500 for a deep lymph node excision of cheek.  Is there another option?  I read that all facial lymph node excisions are superficial, but this one goes down to muscle.   I did question him about using CPT 21013, excision soft tissue, subfascial, but the path came back as a really high level 2 lymph node with granulomatous lymphadentitis.  Any thoughts?


Preoperative Diagnosis 
Localized enlarged lymph nodes

 Right cheek mass

Postoperative Diagnosis 
Same.

Operation 
Excision right cheek mass.

Anesthesia 
Gen.

Estimated Blood Loss 
Minimal.

Findings 
~1.5 cm right deep cheek mass.  Irregular, whitish, firm.  Partially cystic; although mostly solid.  Consistent w/ lymph node vs tumor.  Sent for fresh lymphoma workup and cultures for GS/C&S.

Specimen(s) 
Right cheek.

Complications 
None.

Technique 
 The patient was taken back to the main operating room. General anesthesia was induced without difficulty. Patient was intubated. Following this a shoulder roll was applied.  We marked the planned incision and injected it with _5 mL 1% lidocaine with 1:100,000 epinephrine.  The patient was prepped and draped in the usual fashion.   Several minutes were allowed to lapse.  Thereafter a _2.5 cm incision was made with a bovie in the right buccal mucosa inferiorly through mucosa, subcutaneous tissue, and muscle.  We dissected over and around the mass with the Metzenbaum scissors & using retractors for exposure.  The boundaries were superiorly- the buccal muscle, medially- the mandible, posteriorly- the parotid gland.  It appeared to be consistent with a lymph node vs tumor; whitish with a firm irregular capsule, but also partially cystic.   Hemostasis was achieved with the electrocautery.  Wound bed irrigated thoroughly w/ saline solution.  We placed several pieces of postage stamp size Surgicel into the wound.  We _did not place a #7 flat JP drain.  The wound was closed in layered fashion with 4-0 chromic suture, and the mucosa was closed with a running locking 4-0 chromic.  Antibiotic ointment was applied to the lips.  At the conclusion the patient awoke from anesthesia in good condition. Disposition _she is currently stable in the recovery room.


Thanks for any help,

Kelly - CPC


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## bwolfe1 (Jan 13, 2016)

Nearly all of the lymph nodes in the head, face, and neck are part of the cervical system, some are right near the surface of the skin, usually under the chin and on the back of the neck; many more are deep within the muscular structure.

From the Coding Desk Reference for CPT Code 38500:  The physician performs a biopsy on or removes one or more superficial lymph nodes. The physician makes a small incision through the skin overlying the lymph node. The tissue is dissected to the node. A small piece of the node and surrounding tissue is removed, or the node may be removed. The incision is repaired with a layered closure. Report 38505 if a needle is used; report 38510 if deep cervical nodes are biopsied; report 38520 if deep cervical nodes with excision scalene fat pads are checked; report 38525 if deep axillary nodes are biopsied; and report 38530 if internal mammary nodes are biopsied.


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