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The procedure described by CPT® Code 38510 involves the open biopsy or excision of deep cervical lymph nodes, which are critical components of the lymphatic system located in the neck region. These lymph nodes include specific groups such as the spinal accessory chain, transverse cervical chain, and the Delphian node. The procedure begins with the creation of an incision in the skin over the affected deep cervical lymph nodes, allowing access to the underlying structures. The platysma muscle, a thin layer of muscle in the neck, is then incised to facilitate deeper dissection. Careful dissection through the surrounding soft tissues is essential to protect nearby nerves and blood vessels, which are vital for maintaining normal neck function and sensation. During the procedure, one or more deep cervical lymph nodes are meticulously dissected free from their surrounding tissues and either removed entirely or sampled for further analysis. Additionally, lymph nodes located within the scalene fat pad, which is situated beneath the inferior aspect of the scalene muscle, may also be targeted for biopsy or excision. Accessing these lymph nodes requires a supraclavicular skin incision, which is extended through the platysma muscle and involves dividing the sternocleidomastoid muscle near its attachment to the clavicle. This approach exposes the scalene fat pad, allowing for careful dissection and removal of the fat pad along with any lymph nodes present. The excised tissue samples, lymph nodes, and scalene fat pad are subsequently sent to a laboratory for histological evaluation, which is crucial for diagnosing potential pathologies. It is important to note that CPT® Code 38510 is specifically used when the deep cervical lymph node biopsy or excision is performed without the excision of the scalene fat pad, while CPT® Code 38520 is designated for cases where scalene fat pad excision is included in the procedure.
© Copyright 2025 Coding Ahead. All rights reserved.
The open biopsy or excision of deep cervical lymph nodes, as described by CPT® Code 38510, is indicated for various clinical scenarios. These may include:
The procedure for open biopsy or excision of deep cervical lymph nodes involves several critical steps, which are detailed as follows:
After the completion of the open biopsy or excision of deep cervical lymph nodes, patients may require specific post-procedure care. This typically includes monitoring for any signs of complications such as infection, bleeding, or nerve injury. Patients are often advised to manage pain with prescribed medications and to keep the incision site clean and dry. Follow-up appointments are essential to review histological results and to determine any further treatment based on the findings. Recovery time may vary depending on the extent of the procedure and the patient's overall health, but most individuals can expect to resume normal activities within a few days, barring any complications.
| Short Descr | BIOPSY/REMOVAL LYMPH NODES | Medium Descr | BX/EXC LYMPH NODE OPEN DEEP CERVICAL NODE | Long Descr | Biopsy or excision of lymph node(s); open, deep cervical node(s) | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 67 - Other therapeutic procedures, hemic and lymphatic system |
This is a primary code that can be used with these additional add-on codes.
| 38900 | Addon Code MPFS Status: Active Code APC N ASC N1 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) |
| LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | SG | Ambulatory surgical center (asc) facility service | X3 | Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2011-01-01 | Changed | Short description changed. |
| 2001-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |