Anesthesia Coding Alert

Question: Which anesthesia code applies to an axillary node excision that is unrelated to a mastectomy?

Maine Subscriber

Answer: Some coders recommend 38740 (Axillary lymphadenectomy; superficial) or 38745 (... complete) for this procedure because these codes represent more involved procedures with excision of fatty tissue, lymph nodes and vessels. But because your question states that the physician excised a node -- not a region -- 38525 (Biopsy or excision of lymph node[s]; open, deep axillary node[s]) is more appropriate.

All three surgical codes cross to anesthesia code 01610 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla). That means your reimbursement will remain the same no matter which surgical code you begin with, but you want to report the most accurate code for the procedure.