Can you spot the difference between a lymph node biopsy and a lymphadenectomy in an operative report? While the two may feel similar, there are a few key differences that separate these two procedures. Knowing those keys can help you pick out critical details to determine the correct code.
- A lymph node biopsy is the removal of one or more nodes in an anatomic area such as the axilla or the groin.
- The goal of a biopsy is to diagnose or rule out disease in the lymph nodes.
- Think of a lymph node biopsy as “sampling” a node or sometimes a few nodes to see if anything unusual shows up.
- A sentinel node biopsy is a specific biopsy performed on patients with cancer or a high suspicion of cancer. In a sentinel node procedure, the surgeon removes the first lymph nodes into which cancer from nearby areas will typically spread. Sentinel node biopsies are generally performed in the axilla or the groin. The surgeon removes the sentinel node(s) one at a time until only normal appearing lymph nodes remain.
- Biopsies are typically coded based on the approach (open incision vs. needle biopsy) and, in the case of open biopsies, are further defined based on the depth of the biopsy (biopsy of superficial or deep lymph nodes). Deep lymph node biopsies are defined a little differently based on the anatomic site. For example, deep lymph nodes in the cervical (neck) area are those located below the muscle while deep lymph nodes in the axilla are the central and apical nodes which typically require the surgeon to open the deep fat pad and enter the “true axilla” to remove the nodes.
- A lymphadenectomy is the complete removal of a group of lymph nodes in an anatomic area.
- Lymphadenectomies are almost always performed during surgeries to remove cancer that is known or highly suspected to have spread into the lymph nodes.
- The surgeon may also remove surrounding soft tissue around the lymph nodes as well such as muscle, blood vessels, or nerves as needed to ensure that no cancerous tissue is left behind.
- Think of a lymphadenectomy as a “sweep” to clear all lymph nodes in a particular group together.
- Lymphadenectomies are typically coded based on the extent of the lymph node tissue removed (examples are noted below – see your CPT manual for a complete listing of lymphadenectomies in anatomic areas other than the axilla and the cervical area):
- Axillary lymphadenectomies may be superficial (removal of the level I axillary lymph nodes only) or complete (removal of at the level I and level II lymph nodes together). Note that level III nodes are present in some patients and may also be removed in a complete axillary lymphadenectomy if the surgeon decides that is necessary.
- Cervical lymphadenectomies are even further broken down as radical, modified radical, selective, or suprahyoid:
- Radical means a removal of all of the lymph nodes in groups I-V on one side of the neck along with removal of the internal jugular vein (IJV), the spinal accessory nerve (SAN), and the sternocleidomastoid muscle (SCM). Additional soft tissue surrounding the lymph nodes may also be removed as needed.
- Modified radical means removal of all of the lymph nodes in groups I-V on one side of the neck (just like a radical), but at least one of the three soft tissue structures removed during a radical procedure – the IJV, the SAN, or the SCM are preserved and not removed in the modified radical procedure.
- Selective means removal of all lymph nodes in two or more groups on the same side of the neck (e.g., levels II and III on the right, levels II-IV on the left, etc.) with or without removal of the IJV, SAN, or SCM and other surrounding soft tissues as needed.
- Suprahyoid means removal of the level I nodes only.
- Lymphadenectomies may be coded separately with their own code (e.g., CPT 38724 for a modified radical or selective cervical lymphadenectomy) or they may be part of a combination code with another surgical procedure (e.g., CPT 41155 for a composite resection “with” a radical lymphadenectomy in the neck). Either way, the documentation requirements for the lymphadenectomy portion of the case are the same.
Let’s look at a couple of examples and apply the information above to select the best code for the surgery performed on the lymph nodes.
Example #1: The patient is a 37-year-old male who presented to the hospital secondary to hiccups and was ultimately found to have a right axillary mass and noted to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly. The working diagnosis is lymphoma; however, the Hematology and Oncology Departments were requesting a procedure in order to confirm the diagnosis.
INTRAOPERATIVE FINDINGS: The patient was found to have a large right axillary lymphadenopathy, one of the lymph nodes was sent down as a fresh specimen.
PROCEDURE: After informed written consent, risks and benefits of this procedure were explained to the patient. The patient was brought to the operating suite, prepped and draped in a normal sterile fashion. Multiple lymph nodes were palpated in the right axilla; however, the most inferior node was to be removed. First, the skin was anesthetized with 1% lidocaine solution. Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla. Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node. The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then the lymph node was sent as a specimen to the lab. Several hemostats were used; suture ligated with #3-0 Vicryl suture and hemostasis was maintained. Next the deep dermal layers were approximated with #3-0 Vicryl suture. After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending. The patient did tolerate the procedure well. Steri-Strips and sterile dressings were applied, and the patient was transferred to the Recovery in stable condition.
Answer Example #1: The highlighted portions of the note are keys to picking an accurate CPT code. The portion of the note highlighted in green speaks to the intent of the lymph node procedure. The procedure is being performed “to confirm a diagnosis.” This statement makes me consider a biopsy initially since a biopsy is performed to diagnose or rule out disease in the lymph nodes, but I’m going to keep checking the rest of the details in the report. Next, we see some key procedure details highlighted in yellow. We see that there are multiple lymph nodes that can be felt in the right axilla, but only the most inferior (lowest) node will be removed today. So, the surgeon is planning to remove only one node. If we confirm that detail in the rest of the note, that will confirm this is a biopsy rather than a lymphadenectomy since the surgeon would be sampling a single node not taking out an entire group of nodes together. So, at this point, I am more confident this is likely a biopsy and want to start looking for other details like approach and depth that will help me pick the best code. Next, we see that the surgeon makes a 4 cm incision with a #15 blade scalpel which confirms this is an open approach. He continues dissecting down to the lymph node (he is dividing and splitting tissues until he sees the lymph node he wants to remove), and then he excises the one lymph node completely. So that last detail confirming excision of just the one lymph node coupled with the open approach and the indication of confirming a diagnosis confirms that this is an open lymph node biopsy. But what about the depth? This is a little trickier because the surgeon never documents “superficial” or “deep” and doesn’t really call out what layer of tissue he dissects through to expose the lymph node (e.g., skin, subcutaneous, fascia, etc.). To pull the depth of the biopsy out of the note, we have to look at some clues based on how the surgeon closes the incision. We can see that he first closes the deep dermal layer (deep skin layer) and then performs a running subcuticular stitch (a technique used to close the surface of the skin). So, while he never tells us specifically how deep the lymph node is, because he only has to close tissues of the skin, I would take this to be a biopsy of a superficial node.
Putting this all together, we have an open superficial lymph node biopsy of the axilla, or CPT 38500.
Example #2: A 56-year-old gentleman presented after he was recently diagnosed with squamous cell carcinoma of the tongue. After consents were obtained and the patient was sterilely prepped and draped, a #15 blade was used to make an incision on the right side of the neck. Dissection was continued and the sternocleidomastoid muscle was dissected and preserved. We began by excising the group II lymph nodes. The SAN was ligated and sacrificed. We then moved to the level III and IV lymph nodes and excised these nodes in toto. The level V lymph nodes were normal and preserved. The case was then turned over to the plastic surgery team for reconstruction with a free muscle flap. The patient tolerated the procedure well and was moved to recovery.
Answer Example #2: The highlighted portions of the note are keys to picking an accurate CPT code. The portion of the note highlighted in green speaks to the intent of the lymph node procedure. The procedure is being performed “after a recent diagnosis of squamous cell carcinoma (cancer) of the tongue.” There is no mention of removing lymph nodes to try to obtain a diagnosis or rule out disease, and the patient has known cancer. So right off, this doesn’t sound like a biopsy, but let’s keep looking for clues. Next, moving to the details highlighted in yellow, a #15 blade was used to open the right side of the neck (so this is an open approach). Next, we see that the sternocleidomastoid muscle was preserved. This means that it is moved out of the way and not removed. Next the group II lymph nodes are excised. So, we now see an entire group of lymph nodes removed and surrounding soft tissue (the sternocleidomastoid muscle) preserved. This is reading more like a lymphadenectomy, but we are going to continue and confirm the full details. Next, we see that the SAN is ligated and sacrificed (tied off and removed). Then the level III and IV lymph nodes are excised in toto (removed completely). Then finally, the level V lymph nodes are preserved (not removed). So, putting the pieces together, we have a procedure performed on lymph nodes in a patient with known cancer of the tongue; the approach is open; the surgeon removes three entire groups of lymph nodes on the right (groups II-IV); and she preserves one soft tissue structure (the SCM) and removes another soft tissue structure (the SAN).
All details together support a selective cervical lymphadenectomy, or CPT 38724.
Reference:
Example #1 shared fromhttps://www.mtsamples.com/.
