38724

🩺 CPT 38724 — Cervical Lymphadenectomy, Modified Radical Neck Dissection

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📋 Code Description

Cervical lymphadenectomy, modified radical neck dissection

CPT 38724 describes a modified radical neck dissection (MRND) — a comprehensive open surgical procedure involving the systematic removal of all five levels of cervical lymph nodes (Levels I-V) while preserving one or more non-lymphatic structures that are routinely sacrificed in a classic radical neck dissection (38720). The non-lymphatic structures that may be preserved include:

• Spinal accessory nerve (CN XI) — motor nerve to the sternocleidomastoid and trapezius muscles; preservation prevents shoulder drop and trapezius atrophy
• Sternocleidomastoid (SCM) muscle — preservation maintains neck contour and cosmesis
• Internal jugular vein (IJV) — preservation is important when bilateral dissection is planned to avoid cerebral venous outflow obstruction; also improves cosmetic outcome

The MRND is the most commonly performed type of neck dissection in contemporary head and neck oncologic surgery. It achieves the same regional nodal clearance as a radical neck dissection but with significantly reduced functional morbidity by protecting critical neurovascular structures not directly involved by tumor.

📌 Key Conceptual Distinction:

• 38720 — Radical neck dissection: Levels I-V removed with sacrifice of the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein
• 38724 — Modified radical neck dissection: Levels I-V removed with preservation of one or more of those three structures
• Selective neck dissection (e.g., 38700, 38510): Only specific nodal levels removed — not all five levels

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🗂️ Code Type & Classification

Field	Detail
CPT Code	38724
Code Type	Category I CPT
Section	Surgery - Hemic and Lymphatic Systems
Subsection	Excision - Lymph Nodes and Lymphatic Channels
Procedure Type	Open cervical lymphadenectomy
Dissection Extent	All five cervical lymph node levels (I-V)
Preserved Structures	≥1 of: spinal accessory nerve, SCM, internal jugular vein
Global Period	90 days
wRVU	14.91
Assistant Payable	✅ Yes
Bilateral	❌ Not inherently bilateral — requires modifier -50 or -RT/-LT
Add-On Code	❌ No
Co-Surgeon	✅ May apply — common in composite head and neck resections
Facility Only	✅ Performed in hospital operating room
Anesthesia	General anesthesia required

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🧭 Anatomic Overview — Cervical Lymph Node Levels I-V

The cervical lymph node classification system divides the neck into six anatomical levels. 38724 addresses Levels I through V as a comprehensive dissection:

Level I — Submental & Submandibular Triangles

• IA (Submental): Between the anterior digastric muscles; drains chin, central lower lip, tip of tongue
• IB (Submandibular): Within the submandibular triangle; drains oral cavity, anterior nasal cavity, submandibular gland
• Key structures at risk: Marginal mandibular branch of CN VII, lingual nerve (CN V3), hypoglossal nerve (CN XII)

Level II — Upper Jugular Group

• IIA: Anterior to the spinal accessory nerve along the upper internal jugular chain
• IIB: Posterior to the spinal accessory nerve (submuscular recess)
• Boundaries: Skull base superiorly to the hyoid bone / carotid bifurcation inferiorly
• Key structures at risk: Spinal accessory nerve (CN XI), internal jugular vein, hypoglossal nerve, vagus nerve
• Drains: Oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, parotid gland

Level III — Middle Jugular Group

• Boundaries: Hyoid / carotid bifurcation superiorly to the cricothyroid membrane / omohyoid muscle inferiorly
• Key structures at risk: Internal jugular vein, common carotid artery, vagus nerve
• Drains: Oral cavity, oropharynx, hypopharynx, larynx, thyroid

Level IV — Lower Jugular Group

• Boundaries: Cricothyroid membrane / omohyoid superiorly to the clavicle inferiorly
• Key structures at risk: Internal jugular vein, thoracic duct (left side), phrenic nerve, brachial plexus, subclavian vessels
• Drains: Hypopharynx, larynx, thyroid, cervical esophagus

Level V — Posterior Triangle Group

• VA: Upper posterior triangle (above the spinal accessory nerve crossing)
• VB: Lower posterior triangle (below CN XI; includes supraclavicular nodes)
• Boundaries: Anterior border of the trapezius, posterior border of the SCM, clavicle
• Key structures at risk: Spinal accessory nerve, phrenic nerve, brachial plexus, external jugular vein, transverse cervical vessels
• Drains: Scalp (posterior), skin of neck, nasopharynx, thyroid

📌 Level VI (central compartment — prelaryngeal, pretracheal, paratracheal nodes) is not included in 38724. Central compartment dissection is reported with thyroid/parathyroid surgery codes or separately when performed.

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🔬 Modified Radical Neck Dissection — Types

The MRND is further classified based on which of the three non-lymphatic structures are preserved:

MRND Type	Preserved Structure(s)	Common Indication
Type I	Spinal accessory nerve (CN XI) only	N2 disease where SCM and IJV involved but CN XI free
Type II	Spinal accessory nerve + SCM	Bulky nodal disease involving IJV
Type III	Spinal accessory nerve + SCM + internal jugular vein	Most common MRND; functional neck dissection equivalent

🔑 Type III MRND (preservation of all three structures) is the most widely performed and functionally superior variant. It is often used synonymously with “functional neck dissection” in the literature. The operative report must document which structures are preserved and which are sacrificed to support the correct CPT code selection between 38720 (radical) and 38724 (modified radical).

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🔬 Procedure Details — Surgical Steps

A standard modified radical neck dissection includes:

1. Positioning: Patient supine, neck extended (shoulder roll), head turned away from operative side; arms tucked; facial nerve monitoring electrodes placed if parotid involvement anticipated
2. Incision: MacFee (two parallel horizontal incisions), modified Schobinger (utility incision), or Y-shaped incision depending on prior surgery, radiation history, and planned reconstruction
3. Subplatysmal flap elevation: Flaps raised superiorly to the mandibular border and anteriorly to midline; posteriorly to the anterior border of the trapezius; inferiorly to the clavicle
4. Identification of landmarks: External jugular vein, greater auricular nerve, spinal accessory nerve identified at Erb’s point; sternocleidomastoid mobilized
5. Level V dissection: Posterior triangle cleared from trapezius forward; spinal accessory nerve traced and protected through its course in the posterior triangle
6. Inferior dissection: Omohyoid muscle divided; thoracic duct (left side) or right lymphatic duct identified and ligated at the junction of the internal jugular vein and subclavian vein; phrenic nerve identified and preserved on the anterior scalene
7. Level IV and III dissection: Jugular chain cleared from clavicle upward; carotid sheath entered; IJV and common carotid artery dissected free
8. Level II dissection: Upper jugular chain cleared; CN XI traced from posterior triangle through the submuscular recess (Level IIB); hypoglossal nerve and vagus nerve identified and protected
9. Level I dissection: Submandibular triangle cleared; submandibular gland typically removed (Level IB); facial vessels ligated; marginal mandibular nerve protected
10. En bloc specimen removal: All nodal-fibrofatty tissue from Levels I-V removed as a single or staged specimen
11. Hemostasis: Meticulous hemostasis of all cervical vessels; clips and ties applied; carotid artery inspected for adventitial integrity
12. Drain placement: Two closed suction drains placed (one anterior, one posterior)
13. Wound closure: Platysma reapproximated; skin closed in layers; consider reconstructive flap coverage if skin or soft tissue defects present

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💊 wRVU & Reimbursement Summary

Component	Value
Work RVU (wRVU)	14.91
Global Period	90 days
Pre-Operative Period	1 day
Post-Operative Care	Included (routine 90-day global follow-up)
Assistant at Surgery	✅ Payable — document medical necessity
Co-Surgeon	✅ May apply — payer-specific; document distinct roles
Bilateral	Requires modifier 50 or RT/LT per payer policy
Facility Only	✅ Performed in hospital OR; no non-facility RVU differential

💡 The wRVU of 14.91 reflects the substantial operative complexity and time investment of a comprehensive five-level cervical dissection. This is nearly double the wRVU of 38700 (8.55 wRVU) for suprahyoid dissection alone, and slightly less than the full radical neck dissection (38720; 17.57 wRVU), reflecting the comparative ease of preserving — rather than sacrificing and managing — the critical neurovascular structures.

💡 When 38724 is performed simultaneously with a primary head and neck resection (e.g., total laryngectomy, glossectomy, parotidectomy, thyroidectomy), both codes are reportable with modifier 51 on the secondary procedure — subject to NCCI and payer-specific bundle edits.

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🔁 Bilateral Considerations

38724 is a unilateral procedure by description. Bilateral modified radical neck dissection may be performed in the same operative session for:

• Midline oral cavity or oropharyngeal cancers with bilateral nodal risk
• Thyroid malignancy with bilateral cervical involvement
• Bilateral clinical or radiographic nodal disease

Scenario	Correct Reporting
Bilateral MRND, same session	38724 - 50 or 38724 - RT + 38724 - LT - 51
Right neck dissection only	38724 - RT
Left neck dissection only	38724 - LT
Two surgeons simultaneously, bilateral	38724 - 62 on each claim (distinct documented roles)

⚠️ Bilateral simultaneous IJV sacrifice risk: Bilateral simultaneous sacrifice of both internal jugular veins carries life-threatening risk of cerebral venous hypertension, massive facial edema, and stroke. Type III MRND (IJV preservation) on at least one side is strongly preferred when bilateral dissection is performed in one session. This oncologic decision should be reflected in the operative note and may influence code selection.

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🔁 Common Modifiers Used With 38724

Modifier	Description & Use
50	Bilateral procedure — bilateral MRND performed in the same operative session
51	Multiple procedures — when 38724 is performed with a primary head and neck resection in the same session
59	Distinct procedural service — when payer incorrectly bundles 38724 with a concurrent primary procedure
XS	Separate structure — NCCI-preferred alternative to 59 in applicable contexts
RT	Right side — right cervical modified radical neck dissection
LT	Left side — left cervical modified radical neck dissection
80	Assistant surgeon — payable; document medical necessity (required for complex neurovascular dissection)
62	Co-surgeon — when two surgeons of different specialties perform distinct, documented portions simultaneously
22	Increased procedural services — document when significantly increased complexity exists (e.g., prior irradiated field, carotid involvement, skull base extension)
52	Reduced services — rarely applicable; only if procedure is significantly less than described (e.g., limited by intraoperative findings)
58	Staged/related procedure during global period — planned completion neck dissection after prior sentinel node or elective Level I dissection
79	Unrelated procedure during postoperative period of a prior, unrelated surgery
78	Return to OR for complication during global period — hematoma evacuation, chyle leak requiring surgical revision, wound dehiscence

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✅ Includes

• Open surgical approach with subplatysmal flap elevation
• Comprehensive dissection and removal of all five cervical lymph node levels (I-V) en bloc
• Preservation of one or more of: spinal accessory nerve (CN XI), sternocleidomastoid muscle, internal jugular vein — as documented in the operative report
• Division and ligation of the omohyoid muscle
• Ligation and division of the facial artery and vein (Level I)
• Removal of the submandibular salivary gland (Level IB oncologic clearance)
• Ligation and division of Wharton’s duct
• Identification, dissection, and preservation of the marginal mandibular branch of CN VII
• Identification and preservation of the hypoglossal nerve (CN XII), lingual nerve (CN V3), vagus nerve (CN X), and phrenic nerve
• Ligation of the thoracic duct (left-sided dissection) or right lymphatic duct when encountered
• Intraoperative hemostasis (electrocautery, clips, ligatures)
• Lymphatic channel ligation and management throughout the dissection bed
• Closed suction drain placement (typically two drains — anterior and posterior)
• Layered platysma and skin closure
• Routine pathologic submission of the entire dissection specimen

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❌ Excludes / Do Not Report Separately

Excluded Code / Scenario	Reasoning / Correct Action
38720 (Radical neck dissection)	If ALL three non-lymphatic structures (CN XI, SCM, IJV) are sacrificed, 38720 applies — not 38724
38700 (Suprahyoid lymphadenectomy)	Level I dissection is included within 38724 — do not separately report 38700 for the same side and session
38510 (Deep cervical node excision)	Included within the comprehensive five-level dissection of 38724
38520 (Deep cervical with scalene fat pad excision)	Scalene fat pad excision, if performed as part of Level IV/V clearance, may be bundled — review NCCI
42440 (Excision of submandibular gland)	Submandibular gland removal as part of Level IB dissection is bundled into 38724 — do not separately report
38792 / 38900 (Sentinel node mapping/injection)	When performed as a prelude to a planned 38724, review NCCI edits carefully; typically bundled in same session
Drain placement (separately)	Closed suction drain placement is integral to and bundled within 38724
Wound closure codes (12031-13133)	Neck incision closure is bundled — do not separately report repair codes for the cervical wound
64742 (Division or avulsion of facial nerve branch)	Not applicable when the marginal mandibular nerve is intentionally preserved; only reportable if separately sacrificed for oncologic necessity with distinct documentation
Intraoperative nerve monitoring (IONM)	If performed by a separate qualified provider, may be separately billable — do not include in 38724 RVU
Frozen section interpretation (pathology)	Billed separately by pathology under appropriate pathology CPT codes; not bundled into 38724

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📊 Code Tree — Cervical & Regional Lymphadenectomy

### 🔶 Suprahyoid / Level I Only
[[38700]] - Suprahyoid lymphadenectomy (Level I — submental + submandibular)

### 🔶 Cervical Lymphadenectomy — Complete Radical & Modified Radical
[[38720]] - Cervical lymphadenectomy, complete radical neck dissection
  (Levels I-V + sacrifice of CN XI, SCM, IJV)
**[[38724]]** - Cervical lymphadenectomy, **modified radical neck dissection** ✅ ← YOU ARE HERE
  (Levels I-V + preservation of ≥1 of: CN XI, SCM, IJV)

### 🔶 Deep Cervical Node Excision (Limited / Selective)
[[38510]] - Open excision of deep cervical node(s)
[[38520]] - Open excision of deep cervical node(s) with scalene fat pad excision

### 🔶 Open Biopsy / Non-Site-Specific
[[38500]] - Open superficial lymph node biopsy (non-site-specific)
[[38525]] - Open deep axillary node(s)
[[38530]] - Open internal mammary node(s)
[[38531]] - Open inguinofemoral node(s)

### 🔶 Limited Lymphadenectomy for Staging
[[38562]] - Limited lymphadenectomy for staging; pelvic and para-aortic
[[38564]] - Limited lymphadenectomy for staging; retroperitoneal

### 🔶 Thoracic / Abdominal Lymphadenectomy
[[38746]] - Thoracic lymphadenectomy, regional, unilateral
[[38747]] - Abdominal lymphadenectomy, regional, unilateral

### 🔶 Laparoscopic Lymph Node Procedures
[[38570]] - Laparoscopic retroperitoneal lymph node sampling
[[38571]] - Laparoscopic bilateral total pelvic lymphadenectomy
[[38572]] - Laparoscopic bilateral total pelvic lymphadenectomy + periaortic sampling

### 🔶 Sentinel Lymph Node
[[38792]] - Injection of radioactive tracer for preoperative sentinel node ID
[[38900]] - Intraoperative lymphatic mapping (add-on)

### 🔶 Oral Cavity / Head & Neck Resections — Commonly Combined With [[38724]]
[[41130]] - Hemiglossectomy
[[41135]] - Partial glossectomy with unilateral radical neck dissection
[[41140]] - Glossectomy, complete or total, without radical neck dissection
[[41145]] - Glossectomy, complete or total, with unilateral radical neck dissection
[[41150]] - Composite resection (tongue, floor of mouth, mandibular bone, neck dissection)
[[41153]] - Composite resection with contralateral radical neck dissection
[[41155]] - Composite resection (Commando procedure) with ipsilateral radical neck dissection
[[42410]] - Excision of parotid tumor; lateral lobe, without nerve dissection
[[42415]] - Excision of parotid tumor; lateral lobe, with dissection and preservation of CN VII
[[42420]] - Excision of parotid tumor; total, with dissection and preservation of CN VII
[[42425]] - Excision of parotid tumor; total, en bloc removal with sacrifice of CN VII
[[42426]] - Excision of parotid tumor; total, with unilateral radical neck dissection
[[60252]] - Thyroidectomy, total or complete, for malignancy with limited neck dissection
[[60254]] - Thyroidectomy, total or complete, for malignancy with radical neck dissection

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🏥 MS-DRG Considerations (Inpatient Setting)

⚠️ In the inpatient hospital setting, CPT codes are not used for claim submission. All procedures are reported using ICD-10-PCS, and MS-DRG assignment is driven by the principal diagnosis, ICD-10-PCS procedure codes, and CC/MCC status.

ICD-10-PCS Equivalent Logic for Modified Radical Neck Dissection

PCS Character	Value
Section	0 - Medical and Surgical
Body System	7 - Lymphatic and Hemic Systems
Root Operation	T - Resection (complete removal of body part) or B - Excision (partial, with qualifier X for diagnostic)
Body Parts	1 - Lymphatic, Right Neck; 2 - Lymphatic, Left Neck (also code Level I and Level V separately if applicable)
Approach	0 - Open
Device	Z - No Device
Qualifier	Z - No Qualifier (therapeutic) or X - Diagnostic

Commonly Used PCS Codes for MRND:

• 07T10ZZ — Resection of Right Neck Lymphatic, Open Approach
• 07T20ZZ — Resection of Left Neck Lymphatic, Open Approach
• 07T00ZZ — Resection of Head Lymphatic, Open (Level I / submental-submandibular)
• 0CT90ZZ — Resection of Right Submandibular Gland, Open (if Level IB includes gland removal)
• 0CTB0ZZ — Resection of Left Submandibular Gland, Open

📌 The ICD-10-PCS body part values for neck lymphatics do not distinguish Levels I-V individually — the “Neck” body part value encompasses the cervical nodal chain. When Level I nodes (submandibular/submental) are also resected, a separate PCS code for Head Lymphatic resection may be required in addition to the Neck Lymphatic resection code, as these map to different body part values in the PCS table.

📌 When the submandibular gland is removed as part of Level IB clearance, an additional PCS code for gland resection is required — the lymphatic and salivary gland body parts are distinct in ICD-10-PCS and must be coded separately.

Relevant MS-DRGs

MS-DRG	Description	Type
011	Tracheostomy for Face, Mouth & Neck Diagnoses w MCC	Surgical
012	Tracheostomy for Face, Mouth & Neck Diagnoses w CC	Surgical
013	Tracheostomy for Face, Mouth & Neck Diagnoses w/o CC/MCC	Surgical
132	Cranial/Facial Procedures w MCC	Surgical
133	Cranial/Facial Procedures w CC	Surgical
134	Cranial/Facial Procedures w/o CC/MCC	Surgical
146	Ear, Nose, Mouth & Throat Malignancy w MCC	Medical
147	Ear, Nose, Mouth & Throat Malignancy w CC	Medical
148	Ear, Nose, Mouth & Throat Malignancy w/o CC/MCC	Medical
168	Mouth Procedures w MCC	Surgical
169	Mouth Procedures w CC	Surgical
170	Mouth Procedures w/o CC/MCC	Surgical
186	Larynx & Other ENT Procedures w MCC	Surgical
187	Larynx & Other ENT Procedures w CC	Surgical
188	Larynx & Other ENT Procedures w/o CC/MCC	Surgical
290	Thyroid Procedures w MCC	Surgical
291	Thyroid Procedures w CC	Surgical
292	Thyroid Procedures w/o CC/MCC	Surgical
820	Lymphoma & Leukemia w Major O.R. Procedure w MCC	Surgical
821	Lymphoma & Leukemia w Major O.R. Procedure w CC	Surgical
822	Lymphoma & Leukemia w Major O.R. Procedure w/o CC/MCC	Surgical

📌 DRG assignment is driven by:

1. Principal diagnosis (e.g., oral cavity SCC, thyroid malignancy, lymphoma, unknown primary)
2. ICD-10-PCS procedure codes — OR vs. non-OR procedure status
3. CC/MCC status — comorbidities and complications significantly affect tier and reimbursement
4. Additional procedures (concurrent resection codes may shift the DRG)

For a patient with oral tongue SCC undergoing hemiglossectomy + MRND, DRG 168-170 (Mouth Procedures) typically applies. For thyroid malignancy with MRND, DRG 290-292 (Thyroid Procedures) applies. Always validate through your facility’s grouper software.

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🧾 Common ICD-10-CM Diagnosis Codes Used With 38724

HCC = Hierarchical Condition Category (CMS-HCC Risk Adjustment). Primary and secondary malignant neoplasms carry significant HCC risk-adjustment weight.

🔸 Oral Cavity Malignancies — Primary Driver

ICD-10-CM Code	Description	HCC
C02.1	Malignant neoplasm of border of tongue	✅ HCC 11
C02.3	Malignant neoplasm of anterior two-thirds of tongue, part unspecified	✅ HCC 11
C02.9	Malignant neoplasm of tongue, unspecified	✅ HCC 11
C04.0	Malignant neoplasm of anterior floor of mouth	✅ HCC 11
C04.1	Malignant neoplasm of lateral floor of mouth	✅ HCC 11
C04.9	Malignant neoplasm of floor of mouth, unspecified	✅ HCC 11
C05.0	Malignant neoplasm of hard palate	✅ HCC 11
C06.0	Malignant neoplasm of cheek mucosa	✅ HCC 11
C06.2	Malignant neoplasm of retromolar area	✅ HCC 11
C03.0	Malignant neoplasm of upper gum	✅ HCC 11
C03.1	Malignant neoplasm of lower gum	✅ HCC 11
C00.1	Malignant neoplasm of external lower lip	✅ HCC 11

🔸 Oropharynx, Hypopharynx & Larynx — Common Drivers

ICD-10-CM Code	Description	HCC
C09.0	Malignant neoplasm of tonsillar fossa	✅ HCC 11
C09.1	Malignant neoplasm of tonsillar pillar	✅ HCC 11
C09.9	Malignant neoplasm of tonsil, unspecified	✅ HCC 11
C10.0	Malignant neoplasm of vallecula	✅ HCC 11
C10.1	Malignant neoplasm of anterior (lingual) surface of epiglottis	✅ HCC 11
C10.3	Malignant neoplasm of posterior wall of oropharynx	✅ HCC 11
C10.9	Malignant neoplasm of oropharynx, unspecified	✅ HCC 11
C11.9	Malignant neoplasm of nasopharynx, unspecified	✅ HCC 11
C12	Malignant neoplasm of pyriform sinus	✅ HCC 11
C13.9	Malignant neoplasm of hypopharynx, unspecified	✅ HCC 11
C32.0	Malignant neoplasm of glottis	✅ HCC 11
C32.1	Malignant neoplasm of supraglottis	✅ HCC 11
C32.9	Malignant neoplasm of larynx, unspecified	✅ HCC 11

🔸 Thyroid & Salivary Gland Malignancies

ICD-10-CM Code	Description	HCC
C73	Malignant neoplasm of thyroid gland	✅ HCC 11
C07	Malignant neoplasm of parotid gland	✅ HCC 11
C08.0	Malignant neoplasm of submandibular gland	✅ HCC 11
C08.9	Malignant neoplasm of major salivary gland, unspecified	✅ HCC 11

🔸 Skin Malignancies — Head/Neck Drainage (Melanoma, CSCC, MCC)

ICD-10-CM Code	Description	HCC
C43.0	Malignant melanoma of lip	✅ HCC 12
C43.30	Malignant melanoma of unspecified part of face	✅ HCC 12
C43.39	Malignant melanoma of other parts of face	✅ HCC 12
C43.4	Malignant melanoma of scalp and neck	✅ HCC 12
C44.319	Basal cell carcinoma of skin of other and unspecified parts of face	✅ HCC 12
C44.329	Squamous cell carcinoma of skin of other and unspecified parts of face	✅ HCC 12
C44.40	Unspecified malignant neoplasm of skin of scalp and neck	✅ HCC 12
C4A.4	Merkel cell carcinoma of scalp and neck	✅ HCC 12

🔸 Secondary / Metastatic Nodal Disease — Neck

ICD-10-CM Code	Description	HCC
C77.0	Secondary and unsp malignant neoplasm of lymph nodes of head, face, and neck	✅ HCC 11
C77.8	Secondary and unsp malignant neoplasm of lymph nodes of multiple regions	✅ HCC 11
C77.9	Secondary malignant neoplasm of lymph node, unspecified	✅ HCC 11

🔸 Lymphoma — Cervical Involvement

ICD-10-CM Code	Description	HCC
C81.01	Nodular lymphocyte predominant Hodgkin lymphoma, head/face/neck nodes	✅ HCC 10
C81.91	Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck	✅ HCC 10
C83.31	Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck	✅ HCC 10
C85.11	Unspecified B-cell lymphoma, lymph nodes of head, face, and neck	✅ HCC 10

🔸 Unknown Primary — Cervical Metastasis

ICD-10-CM Code	Description	HCC
C80.1	Malignant (primary) neoplasm, unspecified	✅ HCC 11
C77.0	Secondary malignant neoplasm, head/face/neck nodes (when primary unknown)	✅ HCC 11

🔸 Benign / Inflammatory Indications (Rare for MRND)

ICD-10-CM Code	Description	HCC
R59.0	Localized enlarged lymph nodes	❌
L04.0	Acute lymphadenitis, face, head, and neck	❌
I88.1	Chronic lymphadenitis, except mesenteric	❌

🔸 Postoperative & Complication Codes (Inpatient Context)

ICD-10-CM Code	Description	HCC
J95.04	Transtracheal airway obstruction (post-neck surgery complication)	❌
I97.710	Intraoperative cardiac arrest during other surgery	❌
T81.32XA	Disruption of external operation wound, NEC, initial encounter	❌
G52.10	Disorder of accessory nerve, unspecified (CN XI injury post-dissection)	❌
G52.3	Disorders of hypoglossal nerve (CN XII injury)	❌
J39.0	Retropharyngeal and parapharyngeal abscess (post-op complication)	❌
I89.0	Lymphedema, not elsewhere classified (post-neck dissection sequela)	❌

📌 Sequencing Guidance — Inpatient:

• Sequence the primary malignancy as the principal diagnosis when the MRND is part of a planned oncologic resection
• C77.0 is an additional diagnosis in the presence of a known primary
• For unknown primary with cervical metastasis, C77.0 may serve as the principal diagnosis with C80.1 as an additional code
• For lymphoma, sequence the lymphoma as principal; cervical node involvement is captured in the site-specific ICD-10-CM lymphoma code

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💡 Coding Examples

Example 1 — MRND for Oral Tongue SCC, Right, Unilateral

Clinical Scenario:
A 61-year-old male with T3N2b squamous cell carcinoma of the right lateral tongue border undergoes right hemiglossectomy with right modified radical neck dissection (Type III — all three structures preserved). The spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein are all preserved. Levels I-V are cleared en bloc.

Correct Coding:

• 41130 — Hemiglossectomy (primary procedure — highest value)
• 38724 - RT - 51 — Modified radical neck dissection, right (secondary procedure)
• C02.1 — Malignant neoplasm of border of tongue (principal)
• C77.0 — Secondary malignant neoplasm, head/face/neck lymph nodes (additional)

✅ 38724 with RT + 51. Submandibular gland removal in Level IB is bundled — do not separately report 42440.

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Example 2 — MRND Type I (CN XI Preserved Only) for Advanced Nodal Disease

Clinical Scenario:
A 55-year-old female with T2N2c SCC of the floor of mouth undergoes bilateral floor-of-mouth resection and bilateral modified radical neck dissections. On the left side, the SCM and IJV are sacrificed due to direct tumor involvement but the spinal accessory nerve is preserved (Type I MRND). On the right, a Type III MRND is performed.

Correct Coding:

• 41150 — Composite resection, floor of mouth, mandibular bone, with neck dissection (primary)
• 38724 - LT - 51 — Modified radical neck dissection, left (Type I — CN XI preserved, SCM + IJV sacrificed)
• 38724 - RT - 51 — Modified radical neck dissection, right (Type III)
• C04.0 — Malignant neoplasm of anterior floor of mouth

✅ Both sides report 38724 because at least one non-lymphatic structure is preserved on each side. If the left side had sacrificed all three structures, 38720 - LT would be the correct code for the left dissection.

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Example 3 — Bilateral MRND for Thyroid Malignancy

Clinical Scenario:
A 48-year-old female with papillary thyroid carcinoma with bilateral cervical lymph node metastases (N1b) undergoes total thyroidectomy with bilateral modified radical neck dissection. All three non-lymphatic structures are preserved bilaterally (Type III).

Correct Coding:

• 60254 — Total thyroidectomy for malignancy with radical neck dissection (primary — note: 60254 includes neck dissection by definition; review NCCI edits before separately reporting 38724)
• Alternatively, if 60252 is used (limited neck dissection):
• 60252 — Total thyroidectomy for malignancy with limited neck dissection
• 38724 - 50 - 51 — Bilateral MRND (if payer policy and NCCI edits permit separate reporting)
• C73 — Malignant neoplasm of thyroid gland
• C77.0 — Secondary malignant neoplasm, head/face/neck lymph nodes

⚠️ Critical NCCI Note: 60254 includes neck dissection within its descriptor. Review current NCCI edits before separately reporting 38724 with 60254 — unbundling may result. When the neck dissection is more extensive than what 60254 describes, modifier 22 on 60254 may be appropriate in lieu of separately reporting 38724.

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Example 4 — MRND With Parotidectomy for Parotid Malignancy

Clinical Scenario:
A 67-year-old male with high-grade mucoepidermoid carcinoma of the right parotid gland with cervical lymph node metastases undergoes right total parotidectomy with CN VII preservation and right modified radical neck dissection (Type III).

Correct Coding:

• 42420 — Excision of parotid tumor, total, with CN VII preservation (primary — highest value)
• 38724 - RT - 51 — Modified radical neck dissection, right (secondary)
• C07 — Malignant neoplasm of parotid gland
• C77.0 — Secondary malignant neoplasm, head/face/neck lymph nodes

✅ Both codes reportable. Confirm NCCI edit status between 42420 and 38724 — if bundled, modifier 59 or XS may be needed with documentation of distinct procedure and anatomic site.

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Example 5 — Staged Completion MRND After Positive Sentinel Node Biopsy

Clinical Scenario:
A patient had a right cervical sentinel lymph node biopsy 18 days ago for a T2 melanoma of the right scalp. Pathology confirmed metastatic melanoma in one sentinel node. The patient now returns for a right completion modified radical neck dissection (Type III).

Correct Coding:

• 38724 - RT - 58 — Right modified radical neck dissection; staged/related procedure within global period of prior sentinel node biopsy
• C77.0 — Secondary malignant neoplasm, head/face/neck lymph nodes
• C43.4 — Malignant melanoma of scalp and neck (primary)

✅ Modifier 58 documents this as a planned staged procedure within the global period of the prior sentinel node biopsy — prevents denial while accurately reflecting the staged oncologic surgical plan.

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Example 6 — Inpatient Laryngeal Cancer With MRND (ICD-10-PCS)

Clinical Scenario:
A 70-year-old male admitted for total laryngectomy for T4a supraglottic SCC with ipsilateral cervical metastases. Right modified radical neck dissection performed concurrently. Right submandibular gland included in specimen.

ICD-10-CM Diagnoses:

• Principal: C32.1 — Malignant neoplasm of supraglottis
• Additional: C77.0 — Secondary malignant neoplasm, head/face/neck lymph nodes

ICD-10-PCS Procedures:

• 0CT30ZZ — Resection of Larynx, Open Approach (total laryngectomy)
• 07T10ZZ — Resection of Right Neck Lymphatic, Open Approach (MRND)
• 07T00ZZ — Resection of Head Lymphatic, Open (Level I — submental/submandibular)
• 0CT90ZZ — Resection of Right Submandibular Gland, Open Approach
• 0B110F4 — Bypass Trachea to Cutaneous (tracheostomy, if performed)

MS-DRG: 186-188 (Larynx & Other ENT Procedures ± CC/MCC), depending on comorbidity burden

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⚠️ Common Coding Pitfalls

• Confusing 38724 with 38720: The critical differentiator is preservation vs. sacrifice of non-lymphatic structures. If the operative note documents sacrifice of all three (CN XI, SCM, IJV), 38720 applies. If any one or more of these is preserved, 38724 is correct. Always read the operative note for explicit documentation of preserved and sacrificed structures.
• Separately billing Level I dissection with 38700: Level I is encompassed within the comprehensive five-level dissection of 38724 — reporting 38700 in addition to 38724 for the same side and session is unbundling.
• Separately billing 42440 for submandibular gland removal: When the submandibular gland is removed as part of Level IB clearance in 38724, it is bundled. Do not separately report 42440.
• Missing bilateral modifier: When bilateral MRND is performed in the same operative session, modifier 50 (or RT/LT per payer) is required. Failure to append the bilateral indicator results in only one-sided reimbursement.
• Unbundling 38724 from composite resection codes: Some oral cavity resection codes (e.g., 41135, 41145, 41150, 41153, 41155, 60254) include neck dissection in their descriptor. Separately reporting 38724 with these codes may constitute unbundling without strong NCCI override documentation. Review current NCCI edits carefully.
• Using CPT codes for inpatient claims: In the inpatient setting, ICD-10-PCS is required. The PCS body part values for neck lymphatics, head lymphatics, and submandibular gland are all distinct — each must be separately coded when resected.
• Omitting submandibular gland PCS code inpatient: When Level IB includes gland removal, a separate PCS Resection code for the submandibular gland is required inpatient — it is a distinct body part from the lymphatic chain.
• Incorrect MS-DRG selection: The principal diagnosis drives DRG family assignment. Oral cavity SCC lands in DRG 168-170; laryngeal cancer in 186-188; thyroid malignancy in 290-292. Coders must sequence principal diagnosis correctly to ensure appropriate DRG grouping.
• Forgetting modifier 22 for significantly increased complexity: When a MRND is performed in a previously irradiated field, involves carotid reconstruction, or has other extraordinary complexity, modifier 22 with detailed operative documentation can support additional reimbursement beyond the standard RVU.

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🔗 Related Codes Quick Reference

Code	Description
38700	Suprahyoid lymphadenectomy (Level I — submental + submandibular)
38720	Cervical lymphadenectomy, complete radical neck dissection (Levels I-V, all structures sacrificed)
38510	Open excision of deep cervical lymph node(s)
38520	Open deep cervical node(s) with scalene fat pad excision
38531	Open biopsy/excision, inguinofemoral nodes
38562	Limited lymphadenectomy for staging; pelvic and para-aortic
38792	Injection of radioactive tracer for preoperative sentinel node ID
38900	Intraoperative lymphatic mapping (add-on)
41130	Hemiglossectomy
41135	Partial glossectomy with unilateral radical neck dissection
41145	Total glossectomy with unilateral radical neck dissection
41150	Composite resection (tongue, floor of mouth, mandible, neck dissection)
41155	Composite resection (Commando) with ipsilateral radical neck dissection
42420	Parotidectomy, total, with CN VII preservation
42426	Parotidectomy, total, with unilateral radical neck dissection
60252	Total thyroidectomy for malignancy with limited neck dissection
60254	Total thyroidectomy for malignancy with radical neck dissection
42440	Excision of submandibular gland (standalone; bundled when part of 38724)
C77.0	Secondary malignant neoplasm, lymph nodes of head, face, and neck
C73	Malignant neoplasm of thyroid gland
R59.0	Localized enlarged lymph nodes

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^{AMA CPT® Professional Edition 2026 | CMS Physician Fee Schedule Look-Up Tool 2026 | CMS NCCI Policy Manual 2026 | CMS ICD-10-CM Official Guidelines FY2026 | CMS MS-DRG Definitions Manual v43 | CMS ICD-10-PCS Official Guidelines FY2026 | AJCC Cancer Staging Manual 9th Ed. — Head & Neck | Shah JP et al. Head and Neck Surgery and Oncology 5th Ed. | Robbins KT et al. Consensus Statement on the Classification and Terminology of Neck Dissection. Arch Otolaryngol Head Neck Surg. 2008 | AMA CPT Assistant Archives}