Advanced Search

General Surgery Coding Alert

Reader Question:

Observe Fascial Layer for Superficial Versus Deep

Published on Thu Jan 01, 2004

Question: How can I distinguish between superficial (38500) and deep (38525) lymph node biopsy?

Virginia Subscriber Answer: In the simplest sense, a superficial biopsy (38500, Biopsy or excision of lymph nodes[s]; open, superficial) describes excision of nodes that occur above the fascial layer. The surgeon simply palpates and cuts down to the node. A deep biopsy or excision (38525, ... open, deep axillary node[s]) occurs below the fascial layer or deep within the tissue, thereby making the node far less accessible.
 
If you do choose to report a deep biopsy (38525), be sure that the surgeon's documentation supports the claim by describing the depth and location of the excised node.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

General Surgery Coding Alert

View All