Question

WHAT IS THE CORRECT CPT 2022 CODES (NOT ICD-10)?

Surgical Case Operative Report Procedure: Excision of left axillary lymph nodes Indications for This female patient had a lumpectomy for a breast lesion approximately 2.5 years ago. She presents with
palpable adenopathy in the left axilla. Procedure: Description of The patient was brought into the operating room and placed on the OR table in the supine position. The left axilla was prepared and
draped in the usual sterile fashion. After an adequate level of Procedure: general anesthesia had been achieved, a knife with a#10 blade was used to make a curvilinear incision in the skin overlying the
adenopathy. This incision was carried down deep through the subcutaneous tissue using a Bovie knife. Babcock forceps were used to grasp the area of tissue surrounding the lymph node, which was
carefully dissected from the surrounding tissues using a Bovie knife and scissors. All vessels encountered were either Bovied or clipped. The wound was irrigated and carefully examined for bleeders.
The subcutaneous tissue was closed using a Vicry1 suture placed in interrupted fashion, and the skin was reapproximated using staples. Drainage was achieved with a Jackson-Pratt drain brought out
through a separate wound. Sterile dressings were applied, and the patient was taken to the recovery room in a stable postoperative condition.

Answer 1

The correct CPT code for the described surgical procedure, "Excision of left axillary lymph nodes," is CPT code 38525.

Step-by-step explanation:

The provided operative report details the surgical excision of left axillary lymph nodes in a patient who had undergone a lumpectomy for a breast lesion 2.5 years prior.

The procedural steps involved the administration of general anesthesia, a curvilinear incision, dissection of the lymph node using a Bovie knife and scissors, hemostasis through Bovie or clipping, closure of subcutaneous tissue with Vicryl sutures, and skin reapproximation with staples. Additionally, a Jackson-Pratt drain was utilized for drainage.

The appropriate CPT code for this procedure is 38525, which specifically encompasses the excision of axillary lymph nodes. CPT code 38525 aligns with the complexity and extent of the described surgical intervention.

It is crucial to select the most accurate CPT code to ensure proper documentation, billing, and reimbursement. In this case, 38525 precisely reflects the nature of the excision of left axillary lymph nodes in the given clinical context.

In summary, CPT code 38525 is the correct code for the reported surgical procedure. It encompasses the key elements of the excision, from the incision and dissection to closure and drainage.

Accurate coding is essential for proper medical record documentation and billing procedures, facilitating transparent communication among healthcare professionals and ensuring fair reimbursement for the provided services.