tci General Surgery Coding Alert - 2004 Issue 1

Reader Question: Observe Fascial Layer for Superficial Versus Deep

Question: How can I distinguish between superficial (38500) and deep (38525) lymph node biopsy?Virginia Subscriber Answer: In the simplest sense, a superficial biopsy (38500, Biopsy or excision of lymph nodes[s]; open, superficial) describes excision of nodes that occur above the fascial layer. The surgeon simply palpates and cuts down to the node. A deep biopsy or excision (38525, ... open, deep axillary node[s]) occurs below the fascial layer or deep within the tissue, thereby making the node far less accessible.  If you do choose to report a deep biopsy (38525), be sure that the surgeon's documentation supports the...

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