Summary & Overview
CPT 38525: Open Deep Axillary Lymph Node Dissection
CPT code 38525 denotes an open deep axillary lymph node dissection performed for investigation or treatment of tumors in the breast or upper torso. This surgical procedure is clinically significant for staging and local control in oncologic care, and it often influences subsequent treatment planning such as systemic therapy or radiation. Nationally, utilization and coverage of axillary node dissection affect surgical oncology workflows, pathology workloads, and hospital procedural throughput.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, common sites of service, and the service type represented by the code. The publication also provides benchmarks and payer coverage patterns where available, notes on coding and billing considerations, and relevant policy updates that influence authorization and payment for surgical lymph node procedures.
The report is intended for coding professionals, surgical and oncology practice managers, revenue cycle teams, and payers seeking clear context on how CPT code 38525 is used in clinical and billing workflows. Data not available in the input is identified explicitly in relevant sections of the full publication.
Billing Code Overview
CPT code 38525 describes the surgical removal of deep axillary lymph nodes via an open incision, performed as part of investigation or treatment of tumors in the breast or upper torso. The procedure may include sending the excised nodes to a laboratory for pathological analysis.
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Service type: Surgical lymph node dissection for oncologic diagnosis or treatment
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Typical site of service: Hospital operating room or ambulatory surgery center
Clinical & Coding Specifications
Clinical Context
A 56-year-old woman with a newly diagnosed invasive ductal carcinoma of the right breast is scheduled for surgical staging and management. Preoperative imaging (mammography and ultrasound) suggests ipsilateral axillary nodal involvement. The surgical oncologist plans an open axillary lymph node dissection to remove level I and II deep axillary lymph nodes for pathologic staging and potential therapeutic control of regional disease. The patient undergoes general anesthesia in an outpatient surgical suite or hospital operating room. Intraoperatively, the surgeon makes an open incision in the axilla, dissects to the deep axillary space, identifies and removes the indicated lymph nodes, and sends specimens to the pathology laboratory for histologic examination. Postoperative workflow includes immediate PACU recovery, pain control, wound care instructions, and scheduling of pathology result review to guide adjuvant therapy decisions such as chemotherapy, radiation, or endocrine therapy.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the physician component of a service that has a technical component (rare for this surgery but applicable if billing interpretation separately). |
50 |