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Question: A patient presented for a superficial axillary lymph node core needle biopsy. The procedure note states the provider performed the biopsy and inserted a soft tissue marker at the same time.

Should I use a breast biopsy code for the procedure?

Oklahoma Subscriber

Answer: No, you shouldn鈥檛 use a breast biopsy code for this procedure if the documentation doesn鈥檛 include mention of a breast biopsy. While the axillary is near the breast, the CPT^庐 code set includes a code that specifies biopsies performed on the axillary lymph nodes.

Instead of choosing a breast biopsy code, you鈥檒l assign 38505 (Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary)) to report the superficial axillary lymph node biopsy and 10035 (Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion) to report the soft tissue marker placement.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC