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Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). PREOPERATIVE DIAGNOSIS:...

Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s).

PREOPERATIVE DIAGNOSIS: Rule out lymphoma. Enlarged lymph node of axillary area on the left.

POSTOPERATIVE DIAGNOSIS: Same.

ANESTHESIA: Local, using 0.5% Marcaine without epinephrine

The patient was brought to the operating room, and after adequate prepping and draping of the left axillary area, a large several-centimeters-in-diameter lymph node was palpated medially and superiorly. The skin overlying this node was infiltrated with 0.5% Marcaine without epinephrine, and the skin was incised over it. We then went down through the subcutaneous fat; bleeders were coagulated with the electrocautery unit or clamped and tied off with 4-0 Vicryl ties. The node was exposed through sharp and blunt dissection while we tried to keep the node intact since these nodes are generally quite friable. Using blunt dissection around the node, we clamped the blood supply in this area and tied it off with 2-0 Vicryl ties. The node was finally freed up and dissected out, passed off the table in a saline sponge, and sent to pathology quickly for definite diagnosis by permanent section. The bleeding was minimal, and after the node was excised, we irrigated the wound area with diluted Betadine saline solution several times and sponged it off. There was no problem with hemostasis, and the axillary areolar tissue was reapproximated with inverting interrupted simple sutures of 2-0 Vicryl. When these were closed, the subcutaneous tissue was reapproximated with inverting interrupted simple sutures of 4-0 PDS and the skin was closed with 4-0 PDS subcuticular-style suture, continuous with the knots buried at both ends. The wound was dressed. The patient seemed to tolerate the procedure well and left the operating room for his room in satisfactory condition.

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Answer #1

According the data provided there is a surgery performed for excision of enlarged lymph node.

CPT code 38525 is assigned to surgery of axillary lymph nodes under surgical procedure and excision of axillary lymph node and lymphatic channel.

Appropriate HCPCS is G0252

CPT modifier is - 59

CPT 88307 for pathology investigation

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