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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/.

If you have been coding vascular surgery or interventional radiology over the past few years, you have likely encountered procedures to insert an iliac branched endograft (IBE) a number of times.

Before we review the codes for an IBE and some of the key guidelines for coding these services, let’s talk more about what an iliac branched endograft is and how to recognize it in an operative report. An iliac branched endograft is a graft inserted into the iliac artery through a catheter where the graft is placed at the iliac bifurcation (the point at which the common iliac artery splits to form the external and internal iliac arteries). This type of graft extends into all three iliac arteries on the same side (i.e., a graft that extends into the right common, right internal, and right external arteries). Think of this point where the graft is placed as an intersection between the three arteries: if you head north, you are on common iliac lane; if you head east in the right leg or west in the left leg, you are on internal iliac avenue; and if you head south you are on external iliac drive. If you are a visual learner and need to see this “intersection” for yourself, check out this link which shows the common, external, and internal iliac arteries and the point where they all come together: https://i.ytimg.com/vi/wdsXmpZIgnM/hqdefault.jpg.

An IBE is placed to treat an aneurysm, a rupture of the artery, or other disease/trauma such as a dissection. An IBE is placed when the goal is to maintain/preserve blood flow into the external and internal iliac arteries despite the presence of an aneurysm or other disease in the artery at a point that would normally compromise blood flow to those arteries.

Coding Tip: Remember, an IBE is a graft that extends into all three iliac arteries – the common, the internal, and the external iliac arteries. If an iliac endograft is placed in the iliac arteries but only extends into one or two of these iliac arteries (e.g., an endograft which extends across the iliac bifurcation into the left common and left external iliac artery without extension into the left internal iliac artery), it is not an IBE. This type of endograft should not be coded with a CPT code for an iliac branched endograft.

Now that we have a good definition of what an iliac branched endograft is, let’s look at how to code the procedure for inserting this type of graft. You will have two different code options:

• + CPT 34717: Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for rupture or other than rupture (e.g. for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral (list separately in addition to code for primary procedure)
• CPT 34718: Endovascular repair of iliac artery not associated with placement of an aorto-iliac artery endograft at the same session by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for other than rupture (e.g. for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral

There is a lot of important terminology in the code descriptions above so let’s break this down a bit at a time.

Timing of the Procedure: The first thing to notice is that the timing of the procedure determines the code selected for the IBE:

1) If the IBE is inserted at the same time (i.e., during the same surgery) as another aorto-iliac endograft, assign CPT code 34717 for your IBE procedure. Notice the plus sign in front of 34717 – this means that the CPT code is an add on code. To report CPT 34717, you must first code one of the following CPT codes for the other aorto-iliac endograft inserted during the same surgery: 34703, 34704, 34705, or 34706,

2) If the IBE is not inserted during the same surgery as another aorto-iliac endograft (e.g., the patient had an aorto-iliac endograft previously and is now having an IBE placed at a later time), you should assign CPT 34718 instead.

Indications: Notice that CPT 34717 is reported for any IBE procedure performed in conjunction with another aorto-iliac endograft procedure, whether the IBE is placed for rupture or for some condition other than rupture (e.g., aneurysm). When it comes to CPT 34718, though, for the stand-alone/isolated IBE procedure, this code is restricted to conditions “other than rupture” per its CPT code description. This is not an oversight in CPT. We have a CPT instructional note under CPT 34718 that states “for placement of an isolated iliac branched endograft for rupture, use 37799.” So for an IBE placed without another aorto-iliac endograft placement during the same surgery, if the indication is rupture, code unlisted CPT 37799 rather than CPT 34718. For a stand-alone/isolated IBE procedure for all other indications other than rupture, CPT 34718 is your code.

What is Included: Whether the IBE is placed at the time of another aorto-iliac endograft placement or separately from that placement, several procedures/services that may be performed during the IBE placement are included:

• Pre-Procedure Sizing and Device Selection: Any angiograms or other imaging to visualize the anatomy of the iliac arteries and determine the diameter of the graft to insert are included in this procedure.
• Ipsilateral Selective Iliac Artery Catheter Placement(s): The term ipsilateral means “same side.” So placing one or more catheters into any of the iliac arteries on the same side where the IBE is placed is included in the procedure. Do not code CPT codes 36140 or 36245-36248 separately with these codes for those ipsilateral catheter placements.
• Radiological Supervision & Interpretation: Any imaging needed to guide the procedure and confirm successful deployment of the IBE (e.g., angiograms) is included in the procedure.
• Extension Grafts from the Aortic Bifurcation through the Internal/External Iliac Arteries and the Common Femoral Artery: Sometimes it is necessary to add another piece of graft called an extension graft above the IBE or below it to seal the graft and prevent continued blood flow into the area of the artery being repaired by the endograft. When these extension grafts are placed anywhere between the aortic bifurcation (the point at which the abdominal aorta splits to form the right and left common iliac arteries) and the common femoral artery (a major artery of the thigh just below the iliac arteries anatomically), including extension grafts in the internal/external iliac arteries which lie between these two points anatomically, the extension grafts cannot be coded separately.
• Treatment Zone Angioplasty/Stenting: The treatment zone in any endograft procedure is defined as all of the vessels into which the graft passes. So in the context of an IBE, the treatment zone would include the common, internal, and external iliac arteries into which the endograft passes. Any angioplasty (enlarging the diameter of the arteries with a balloon or other similar technique) or stenting (placing additional metal or drug-eluting stents in the arteries to keep the arteries open) within the treatment zone for the IBE are not separately billable.

What is not included: Like other aorto-iliac endograft procedures for repair of the abdominal aorta and/or iliac arteries, the following services can be billed in addition to CPT 34718 for a stand-alone/isolated IBE procedure.

• Large Sheath: If a 12 French or larger sheath is used during percutaneous access to deploy an IBE, CPT 34713 can be coded in addition to CPT 34718.
• Open Femoral Artery Exposure: If a cutdown incision is made over the femoral artery to deliver the IBE, CPT 34812 can be coded in addition to CPT 34718.  Alternatively, if a cutdown incision is made over the femoral artery followed by creation of a conduit (attaching a piece of graft to the artery to allow delivery of the IBE or to place the patient onto cardiopulmonary bypass), CPT 34714 can be coded in addition to CPT 34718.
• Open Iliac Artery Exposure: If a cutdown incision is made over the iliac artery to deliver the IBE, CPT 34820 can be coded in addition to CPT 34718.  Alternatively, if a cutdown incision is made over the iliac artery followed by creation of a conduit, CPT 34833 can be coded in addition to CPT 34718.
• Open Brachial Artery Exposure: If a cutdown incision is made over the brachial artery to deliver the IBE, CPT 34834 can be coded in addition to CPT 34718. 
• Open Axillary/Subclavian Artery Exposure: If a cutdown incision is made over the axillary or subclavian artery to deliver the IBE, CPT 34715 can be coded in addition to CPT 34718.  Alternatively, if a cutdown incision is made over the axillary or subclavian artery followed by creation of a conduit, CPT 34716 can be coded in addition to CPT 34718.

Final Coding Tip: Note that the CPT guidelines only address these additional services being billed with CPT 34718 not CPT 34717. While this may feel contradictory at first, it is important to remember that CPT 34717 is an add-on code. That means that CPT 34717 would always be billed with another primary CPT for an aorto-iliac endograft (e.g., 34703, 34704, etc.). Because the CPT guidelines already specify that all of these additional services may be billed with the CPT codes for the primary procedure codes that CPT 34717 would be billed with, it is not necessary for the parenthetical guidelines to be updated to list all of these same services as being billable with the add on code 34717. The intent here is not to say that what is included and what is separately billable in CPT code 34718 is different from what is included and what is separately billable in CPT 34717.

I hope that the guidelines and explanations above help you code IBE procedures with confidence. If you have additional questions about how to code these procedures, feel free to drop your questions in the comments, so we can all learn from each other.