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Outpatient Facility Coding Alert

You Be the Coder:

Consider Your Choices for Neck Biopsy

Question: The pathology report revealed a benign lymph node on the left posterior side of the neck. How would I code for an excision of the left posterior neck mass?

New Hampshire Subscriber

Answer: For any superficial open excision or biopsy you can use code 38500 (Biopsy or excision of lymph node[s]; open, superficial). Code 38500 can be used for biopsy or excision of lymph node(s) identified as possibly diseased. The physician might reach this conclusion by visualization or because the mass might be near other diseased tissue. You can report 38500 for any superficial node but it most commonly refers to nodes in the cervical, axillary and inguinal areas.

In the case of a deep excision or biopsy, the appropriate code would be 38510 (... open, deep cervical node[s]).

Tips: The code has to be used only once irrespective of the number of nodes opened in the same area. However, if the physician performs biopsies in other anatomic areas you can report the code again with modifier 59 (Distinct procedural service) to indicate that the physician tested a different area. You’ll append modifier 50 (Bilateral procedure) for biopsies done on the contralateral side.

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