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Reader Question: Report More Extensive Code With Biopsy Incisions

Question: Our physician biopsied a superficial node and a deep axillary node -- both through the same incision. Should I report both procedures?
  
New Mexico Subscriber

Answer: No, you shouldn't report both procedures. Because the physician accessed the nodes through a single incision, you may report only the more extensive code. In this case, that code is 38525 (Biopsy or excision of lymph node[s]; open, deep axillary node[s]), which earns you almost $1,100 in reimbursement.

But if the physician performs the biopsies through different incisions and documents her work, you can report both 38525 and 38500 (... open, superficial), as long as you append modifier -59 (Distinct procedural service) to the less extensive code (in this case, 38500) to indicate an additional anatomic area.