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The procedure described by CPT® Code 38531 involves the open biopsy or excision of inguinofemoral lymph node(s). This surgical intervention is primarily aimed at diagnosing, treating, or preventing the spread of cancer to the lymph nodes located in the groin area. The inguinofemoral lymph nodes are critical in the lymphatic drainage system, particularly for cancers originating from the vulva, penis, anus, and skin of the torso. During this procedure, healthcare professionals may remove cancerous lymph nodes or those that are at a high risk of becoming cancerous. Additionally, the first lymph node in a chain, known as the sentinel node, may be biopsied to check for the presence of cancerous cells. The inguinofemoral region contains a chain of approximately ten superficial lymph nodes situated close to the skin's surface in the upper inner thigh, which drain into three to five deeper nodes located within the connective tissue of the upper thigh. The surgical approach typically involves making an incision in the groin area directly over the involved lymph nodes. Depending on the clinical scenario, the procedure may involve only the superficial nodes or may require dissection through the soft tissues to access the deeper nodes, all while taking care to protect surrounding blood vessels and nerves. During the procedure, one or more lymph nodes are carefully dissected free from the surrounding tissue and either removed entirely or sampled for biopsy. To facilitate healing, a small skin flap may be created to cover the incision, and drainage tubes may be placed to prevent fluid accumulation. The excised lymph nodes or tissue samples are then sent to a laboratory for pathological evaluation, which is reported separately, ensuring that any cancerous changes can be accurately assessed and managed.
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The open biopsy or excision of inguinofemoral lymph node(s) is indicated for several specific clinical scenarios, particularly in the context of cancer diagnosis and management. The following conditions may warrant this procedure:
The procedure for the open biopsy or excision of inguinofemoral lymph node(s) involves several critical steps, each designed to ensure the safe and effective removal of lymphatic tissue for diagnostic or therapeutic purposes. The following outlines the procedural steps:
Post-procedure care following the open biopsy or excision of inguinofemoral lymph node(s) is crucial for ensuring proper recovery and monitoring for any complications. Patients are typically observed for a short period in a recovery area to ensure that they are stable following anesthesia. Instructions for care at the incision site are provided, including keeping the area clean and dry, and monitoring for signs of infection such as increased redness, swelling, or discharge. Patients may experience some discomfort or pain at the incision site, which can usually be managed with prescribed pain relief medications. It is important for patients to follow up with their healthcare provider to discuss the results of the pathological evaluation and to determine any further treatment that may be necessary based on the findings. Additionally, patients should be advised on activity restrictions to allow for proper healing and to avoid strain on the surgical site.
| Short Descr | OPEN BX/EXC INGUINOFEM NODES | Medium Descr | OPEN BIOPSY/EXCISION INGUINOFEMORAL NODES | Long Descr | Biopsy or excision of lymph node(s); open, inguinofemoral node(s) | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 0 - 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 | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | none | MUE | 1 |
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) |
| RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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). | 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). | 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. | 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. | 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). | AG | Primary physician | 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 | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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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| 2019-01-01 | Added | Added |