Clinical Context
A 54-year-old female presents to the outpatient surgical clinic with a persistent, non-tender, palpable lymph node in the left cervical region that has enlarged over six weeks despite conservative management. Physical exam localizes a single superficial mobile node just under the skin. Ultrasound shows a solid lymph node without obvious abscess. The provider schedules an open excisional lymph node biopsy to obtain tissue for histopathology and immunohistochemistry to evaluate for malignancy, lymphoma, or chronic infection. The patient arrives on the day of service, consents for the procedure, and undergoes local or monitored anesthesia care in an ambulatory surgery center or hospital outpatient department. The provider uses sterile technique, makes a skin incision over the superficial node, dissects to the capsule, excises the entire node with minimal surrounding tissue, achieves hemostasis, and closes the wound. Specimen is sent to pathology with appropriate labeling and requisition. Postoperative instructions and wound care are provided and the patient is discharged the same day with follow-up arranged for results and potential further staging or therapy planning based on pathology.
Coding Specifications
| Modifier | Description | When to Use |
|---|
25 | Significant, separately identifiable evaluation and management service on the same day as a procedure | Use when a distinct E/M service was performed and documented on the same day as the excisional biopsy. |
| 26 | Professional component | Use if reporting only the physician’s professional component of a service when a technical component is billed separately (rare for excision but applicable if pathology technical services billed separately).
| 50 | Bilateral procedure | Use when superficial lymph node excisions are performed on both sides in the same session.
| 51 | Multiple procedures | Use when the excisional biopsy is performed along with additional distinct procedures during the same operative session.
| 52 | Reduced services | Use when the procedure is partially reduced or not completed as described by the CPT code.
| 53 | Discontinued procedure | Use when the procedure was started but terminated due to extenuating circumstances.
| 59 | Distinct procedural service | Use to indicate a separate, distinct procedure not normally performed on the same day as another service.
| 62 | Two surgeons | Use when two surgeons work together as primary surgeons performing distinct portions of the procedure.
| 63 | Procedure performed on infants less than 4 kg | Use for neonates meeting the weight criteria.
| 76 | Repeat procedure by same physician | Use when the same provider repeats the procedure later same day (note: 76 is not in the provided list; omitted). |
| 78 | Unplanned return to the operating room for a related procedure during the postoperative period | Use when return to OR for a related procedure is required during global period.
| 79 | Unrelated procedure or service by the same physician during the postoperative period | Use when an unrelated procedure is performed during the global period.
| XP | Separate practitioner | Use when a procedure component is performed by a different practitioner of the same group and needs distinct reporting.
| Taxonomy Code | Specialty | Notes |
|---|
208100000X | General Surgery | Most common specialty performing superficial lymph node excision. |
| 2080P0224X | Surgical Oncology | Performs excisional biopsies for suspected malignancy and staging.
| 207K00000X | Otolaryngology (ENT) | Common for head and neck superficial lymph node excisions.
| 207L00000X | Orthopedic Surgery | Performs superficial node excision when nodes are in the extremities or related to musculoskeletal disease.
| 261QA1900X | Dermatology | Performs superficial lymph node excisions when related to skin malignancies or dermatologic conditions.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
R59.0 | Localized enlarged lymph nodes | Common indication for excisional lymph node biopsy to determine etiology. |
| C77.0 | Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck | Used when malignancy is suspected in cervical nodes; biopsy assists in diagnosis/staging.
| C77.9 | Secondary and unspecified malignant neoplasm of lymph node, unspecified | Applied when nodal metastatic disease is suspected and requires tissue diagnosis.
| D47.1 | Chronic myeloproliferative disease | Lymph node biopsy may be performed when hematologic malignancy or atypical lymphoid proliferation is suspected.
| B95.2 | Streptococcus, group B, as the cause of diseases classified elsewhere | Infectious etiologies may prompt node excision when bacterial infection is suspected and tissue culture/histo needed.
| A18.3 | Tuberculosis of lymph nodes | Excisional biopsy is often required to confirm mycobacterial infection in persistent lymphadenopathy.
| I88.9 | Nonspecific lymphadenitis | Used when lymph node inflammation is the clinical diagnosis; biopsy can differentiate reactive from neoplastic processes.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
10120 | Incision and drainage of hematoma, seroma or fluid collection | May be performed if postoperative seroma or hematoma requires evacuation after excision. |
| 12032 | Repair, intermediate, wounds of scalp, arms, and/or legs; 2.6 cm to 7.5 cm | Closure code commonly used when wound closure after node excision requires intermediate layered closure.
| 11100 | Tangential biopsy of skin; single lesion | Performed when a superficial skin lesion requires biopsy concurrently or as alternative diagnostic tissue sampling.
| 88305 | Level IV surgical pathology, gross and microscopic examination | Pathology reporting code commonly billed by pathology for evaluation of excised lymph node tissue.
| 38525 | Biopsy or excision of lymph node(s); open, deep axillary node(s) | Related when deeper or axillary nodes require a separate, deeper excision.
| 36415 | Collection of venous blood by venipuncture | Often performed preoperatively for labs such as CBC or coagulation studies.