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38765

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CPT Code 38765: Superficial Inguinofemoral Lymphadenectomy, including Cloquet’s node

Official Descriptor

Inguinofemoral lymphadenectomy, superficial, including Cloquet’s node (separate procedure)

Layman’s Description

This procedure involves the surgical removal of the superficial lymph nodes in the groin area (inguinal and femoral regions). It specifically includes the removal of “Cloquet’s node,” which is the highest or most superior deep inguinal lymph node located in the femoral canal. This operation is typically performed to remove cancer that has spread (metastasized) to these lymph nodes from a primary site, such as melanoma on the leg, or cancers of the vulva, penis, or anus.

Key Details & Reimbursement

  • wRVU (2024): 11.59
  • Assistant Surgeon Payable: Yes (Indicator 2). An assistant surgeon may be paid for this procedure when medically necessary.
  • Global Period: 90 days (This is a major surgical procedure).
  • MS-DRG: This CPT code does not map to a single MS-DRG. The MS-DRG is determined by the principal diagnosis (the reason for the surgery), secondary diagnoses, and other procedures performed. Common MS-DRGs this procedure might fall under include:
    • MS-DRG 573-575: Skin Grafts & Musculoskeletal Procedures w/ MCC, w/ CC, or w/o CC/MCC.
    • MS-DRG 746-747: Malignancy, Female Reproductive System w/ MCC or w/ CC.
    • MS-DRG 715-716: Malignancy, Male Reproductive System w/ MCC or w/ CC.

Code-Specific Information

Includes

This code is comprehensive for the superficial dissection and includes:

  • Incision in the groin region.
  • Identification and dissection of the superficial inguinal and femoral lymph node packets.
  • Identification and removal of Cloquet’s node.
  • Ligation and division of lymphatic channels and blood vessels.
  • Placement of a surgical drain (if performed).
  • Standard wound closure.

Excludes

This code does not include:

  • Deep pelvic lymphadenectomy: If lymph nodes deeper in the pelvis (obturator, iliac) are also removed, you would report a different code, such as 38770 (Pelvic lymphadenectomy).
  • The primary procedure: The removal of the primary tumor (e.g., radical vulvectomy, excision of melanoma) is coded separately.
  • Bilateral Procedure: If this procedure is performed on both the right and left groin, you must append modifier -50 (Bilateral Procedure).

The “Separate Procedure” Designation

The term “(separate procedure)” in the CPT descriptor is significant. It means that this procedure is normally considered an integral part of a more extensive procedure performed in the same area.

  • When to code it: You should report 38765 if it is the only procedure performed in that anatomical area, or if it is performed with an unrelated procedure in a different anatomical area.
  • When NOT to code it: You would not typically report 38765 separately if it is performed at the same time and through the same incision as a more extensive procedure, like a radical vulvectomy (56633 - 56637), as the lymphadenectomy is considered a bundled component of the larger procedure. Check NCCI edits for specific code pairs.

Code Tree (Hemic and Lymphatic System)

  • Excision (38300-38794)
    • Radical Lymphadenectomy (Radical Resection of Lymph Nodes)
      • …
      • 38760 - Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy…
      • 38765 - Inguinofemoral lymphadenectomy, superficial, including Cloquet’s node (separate procedure)
      • 38770 - Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure)
      • …

Clinical Indications

This procedure is primarily performed for oncological staging and treatment. Common diagnoses include:

  • Malignant melanoma of the lower limb, perineum, or lower trunk.
  • Squamous cell carcinoma of the skin of the lower limb or perineum.
  • Vulvar cancer.
  • Penile cancer.
  • Anal cancer.
  • Confirmed metastasis to the inguinal lymph nodes from an unknown primary.

Coding Examples

Example 1: Unilateral Groin Dissection for Melanoma

  • Clinical Scenario: A 55-year-old male with a malignant melanoma on his left calf underwent a wide local excision and sentinel lymph node biopsy two weeks ago. The sentinel node in the left groin was positive for metastatic melanoma. He now presents for a completion left superficial inguinofemoral lymphadenectomy.
  • Procedure Performed: Left superficial inguinofemoral lymphadenectomy, including dissection and removal of Cloquet’s node.
  • CPT Coding:
    • CPT 38765-LT (Modifier -LT specifies the left side of the body)
  • ICD-10-CM Coding:
    • ICD-10-CM C77.4: Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes.
    • ICD-10-CM Z85.820: Personal history of malignant melanoma of skin.

ICD-10 Code Details

  • ICD-10-CM C77.4 - Secondary Malignant Neoplasm of Inguinal and Lower Limb Lymph Nodes
    • Description: This code is used when cancer has spread from a primary site to the lymph nodes in the groin or leg. It is the primary diagnosis for the lymphadenectomy procedure.
    • HCC (Hierarchical Condition Category): Yes, HCC 11 (Metastatic Cancer and Acute Leukemia). This indicates a high-risk condition for risk adjustment purposes.

Example 2: Bilateral Groin Dissection for Vulvar Cancer

  • Clinical Scenario: A 68-year-old female is diagnosed with Stage II vulvar squamous cell carcinoma. As part of her staging and treatment, she undergoes a bilateral superficial inguinofemoral lymphadenectomy to check for nodal metastasis. The primary tumor will be removed at a later date.
  • Procedure Performed: Bilateral superficial inguinofemoral lymphadenectomy, including Cloquet’s nodes.
  • CPT Coding:
    • CPT 38765-50 (Modifier -50 indicates a bilateral procedure)
  • ICD-10-CM Coding:

ICD-10 Code Details

  • ICD-10-CM C51.9 - Malignant Neoplasm of Vulva, Unspecified
    • Description: This code is used for a primary cancer of the vulva when the specific location (e.g., labia majora, clitoris) is not specified. It serves as the medical necessity for the lymph node dissection.
    • HCC (Hierarchical Condition Category): Yes, HCC 12 (Metastatic Cancer and Acute Leukemia). Although it’s a primary cancer diagnosis, it falls into a high-risk category.

Documentation & Coding Tips

  1. Laterality: The operative report must specify whether the procedure was performed on the right, left, or bilaterally. Use modifiers -RT, -LT, or -50 accordingly.
  2. Cloquet’s Node: While the code descriptor includes removal of Cloquet’s node, it is best practice for the surgeon to explicitly document its identification and removal to fully support the code.
  3. Depth of Dissection: The surgeon should clearly document that a superficial dissection was performed. If the dissection extends deep to the fascia lata to remove the deep inguinal nodes, the procedure may be better described by a different code or require an unlisted code.
  4. Link to Diagnosis: Ensure the ICD-10 code clearly establishes the medical necessity for the lymphadenectomy (e.g., a known primary malignancy that drains to these nodes or confirmed nodal metastasis).

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