Summary & Overview
CPT 38745: Complete Axillary Lymph Node Dissection
CPT code 38745 represents a complete axillary lymph node dissection, involving removal of all lymph nodes in the axilla below the axillary vein, including deep nodes beneath muscle. This procedure is a key component of surgical management for cancers of the breast and chest when comprehensive nodal clearance is indicated. Nationally, the code matters because it captures a high-complexity surgical service with implications for hospital resource use, perioperative care pathways, and oncology treatment planning.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for when complete axillary dissection is performed, typical settings of care (hospital OR or ambulatory surgical center), and the procedural scope captured by the code. The publication summarizes common billing modifiers associated with the code and highlights benchmarking considerations and coding policy updates relevant to inpatient and outpatient surgical oncology services.
This resource is intended to help billing managers, surgical teams, and compliance staff understand what CPT code 38745 denotes, how it fits into surgical cancer care, and where to look for payer-specific policies and documentation expectations. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 38745 describes the surgical removal of all axillary lymph nodes below the axillary vein, including superficial nodes and those deep beneath muscle layers. This operation typically addresses lymphatic tissue removal for malignant conditions involving the breast or chest.
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Service type: Major surgical lymphadenectomy
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Typical site of service: Hospital operating room or ambulatory surgical center
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Clinical & Coding Specifications
Clinical Context
A typical patient is a 52-year-old woman recently diagnosed with invasive ductal carcinoma of the right breast after core needle biopsy demonstrated malignancy. Preoperative staging with sentinel lymph node biopsy identified suspicious axillary involvement; the multidisciplinary tumor board recommends completion axillary lymph node dissection. The patient is admitted to an outpatient surgical suite or hospital operating room under general anesthesia. The surgical team performs a level I and II axillary lymphadenectomy, removing all palpable and nonpalpable lymph nodes below the axillary vein from superficial fat and deep to pectoralis minor where indicated. Intraoperative steps include patient positioning, a transverse or oblique axillary incision, careful identification and preservation of the long thoracic and thoracodorsal nerves and axillary vein, hemostasis, and placement of a surgical drain. The operative report documents laterality, levels dissected, estimated blood loss, number of nodes removed, measurements of any positive nodes, and any concurrent procedures (for example, partial mastectomy or reconstruction). Postoperative workflow includes recovery in PACU, drain management instructions, pathology submission of nodal tissue, coordination with medical oncology for adjuvant therapy based on nodal status, and outpatient wound and lymphedema surveillance with physical therapy referral as needed.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
LT | Left side | When the axillary dissection is performed on the left side of the body. |