Summary & Overview
CPT 38510: Open Excision or Biopsy of Deep Cervical Lymph Nodes
CPT code 38510 represents an open excision or biopsy of deep lymph nodes in the neck using a scalpel to obtain tissue for diagnostic evaluation. This surgical procedure is clinically important for establishing diagnoses in suspected malignancy, infection, or inflammatory lymphadenopathy, and influences subsequent staging and treatment planning. Nationally, accurate coding of 38510 affects surgical quality reporting, claims adjudication, and utilization monitoring for head and neck surgical services.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for the procedure, common payer coverage considerations, and typical sites of service. The publication outlines coding specificity, where 38510 applies versus other lymph node procedures, and highlights typical documentation elements relevant to claims processing.
This resource is intended to clarify the clinical and billing definition of CPT code 38510, summarize payer coverage scope, and identify areas for coding accuracy and policy attention. Data not available in the input is noted where applicable, and the piece focuses on national-level implications rather than state policy detail.
Billing Code Overview
CPT code 38510 describes an open excision or biopsy of deep cervical (neck) lymph nodes performed with a scalpel. The procedure is used to obtain tissue from lymph nodes located deep within the neck to identify or diagnose the cause of disease in the lymph node or surrounding tissues.
Service type: Surgical biopsy / excision
Typical site of service: Operating room or procedure suite; inpatient or outpatient surgical setting
Clinical & Coding Specifications
Clinical Context
A 54-year-old patient presents with a persistent, enlarging, firm deep cervical mass located beneath the sternocleidomastoid muscle on the left side of the neck. The patient reports progressive swelling for 6 weeks with intermittent night sweats and unexplained weight loss. After outpatient evaluation including history, physical exam, and imaging (contrast-enhanced CT neck) demonstrating a discrete deep lymph node suspicious for malignancy, the surgical team schedules an open excisional biopsy of the deep cervical lymph node under general anesthesia. In the operating room, the surgeon makes a transverse neck incision, dissects through platysma and deep cervical fascia, identifies and isolates the targeted deep lymph node adjacent to vascular structures, and removes the node intact for pathologic analysis. Hemostasis is secured, a drain may be placed if indicated, and the incision is closed in layers. The specimen is sent for histopathology including immunohistochemistry and possible flow cytometry. Typical sites of service include an ambulatory surgical center or hospital outpatient surgery unit. Ancillary personnel include the operating surgeon (often ENT/head and neck surgeon or general surgeon), anesthesiologist, surgical nursing staff, and pathology services for diagnostic interpretation. Billing uses 38510 for the open excision/biopsy of the deep neck lymph node; documentation should support laterality, operative approach, indication, findings, and disposition of the specimen.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
50 | Bilateral procedure | When bilateral deep cervical lymph node excisions are performed and payer requires bilateral reporting |
51 | Multiple procedures | When multiple unrelated surgical procedures are performed at the same operative session |
59 | Distinct procedural service | When a separate anatomic site or separate session justifies reporting 38510 in addition to another procedure |
62 | Two surgeons | When two surgeons work together as primary surgeons, each reporting portion of the procedure |
76 | Repeat procedure by same physician | When the same physician repeats the procedure laterality within the postoperative period (note: 76 not in raw list; excluded) |
22 | Increased procedural services | When operative complexity or prolonged time significantly exceeds typical and documentation supports increased work |
52 | Reduced services | When the procedure is partially reduced or not completed as described |
53 | Discontinued procedure | When the procedure is started but halted for patient safety before completion |
26 | Professional component | When only the professional (interpretive) portion of a service is billed (rare for 38510) |
TC | Technical component | When only the technical component of a service is billed (rare for 38510) |
RT | Right side | When the procedure is performed on the right side and laterality must be reported |
LT | Left side | When the procedure is performed on the left side and laterality must be reported |
59 | Distinct procedural service | When procedural circumstances meet criteria for distinct service reporting (repeat entry for emphasis if used) |
22 | Increased procedural services | When unusual intraoperative findings or extensive dissection required (repeat entry not ideal) |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 208C00000X | Otolaryngology (ENT) | Frequently performs head and neck lymph node excisions |
| 207T00000X | General Surgery | Commonly performs neck dissections and lymph node biopsies |
| 2080P0208X | Oral and Maxillofacial Surgery | May perform deep neck procedures when indicated |
| 207K00000X | Surgical Oncology | Performs diagnostic excisional biopsies in oncologic workups |
| 2084P0802X | Pathology (surgical pathology) | Receives and interprets specimens (diagnostic role) |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
C77.0 | Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck | Used when metastasis to cervical lymph nodes is suspected and an excisional biopsy is required for diagnosis |
C81.9 | Hodgkin lymphoma, unspecified | Lymph node excision may be performed to obtain tissue for lymphoma diagnosis and subtyping |
C83.9 | Non-Hodgkin lymphoma, unspecified | Deep lymph node biopsy is commonly required for definitive histologic and immunophenotypic diagnosis |
R59.0 | Localized enlarged lymph nodes | Symptomatic cervical lymphadenopathy prompting diagnostic excision |
B37.3 | Candidiasis of the mouth and pharynx (example) | Infections can enlarge nodes; included as illustrative cause though less commonly an indication for excisional biopsy |
I88.0 | Nonspecific lymphadenitis | When persistent or atypical lymphadenitis fails conservative therapy, excisional biopsy may be performed |
D47.3 | Castleman disease | Rare lymphoproliferative disorder requiring excision for diagnosis and staging |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
38525 | Open excision of lymph node(s); cervical (superficial) | Performed when superficial cervical nodes are targeted instead of deep nodes; may be billed if superficial node excision is done in same episode |
38745 | Lymph node biopsy, open, intra-abdominal or retroperitoneal | Example of anatomic variation; not performed concurrently but related by technique |
38900 | Lymph node sampling (separate procedure) | May be used when multiple nodes are sampled without formal excision |
10060 | Incision and drainage of abscess; simple or single | Performed when infected lymph node with abscess requires drainage rather than diagnostic excision |
99223 | Initial hospital care, typically 70 minutes or more | Represents inpatient evaluation and management commonly billed preoperatively for complex surgical admissions |