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38780

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🧬CPT 38780: Retroperitoneal lymphadenectomy, extensive, including celia, aortic, and pelvic nodes, with or without removing the vena cava and aorta

Overview

CPT 38780 describes a highly complex and extensive surgical procedure involving the removal of lymph nodes from the retroperitoneal space. This is a major abdominal operation, typically performed for the staging and/or treatment of cancers that are known to metastasize to these lymph nodes, most commonly testicular cancer. The “extensive” nature of this code implies a dissection that goes beyond a standard or limited node sampling and includes multiple nodal basins along the great vessels of the abdomen.

Detailed Description

The surgeon performs this procedure through a large abdominal incision (laparotomy). The goal is to remove all identifiable lymphatic tissue in the retroperitoneum within specific anatomical boundaries. The dissection involves carefully mobilizing the intestines and other organs to expose the aorta and inferior vena cava.

The procedure includes the removal of:

  • Celiac nodes: Lymph nodes around the celiac artery.
  • Aortic nodes: Lymph nodes surrounding the aorta (paraaortic, preaortic, postaortic).
  • Pelvic nodes: Lymph nodes along the common, external, and internal iliac vessels.

The phrase “with or without removing the vena cava and aorta” does not mean the vessels are always removed. Instead, it indicates the complexity of the dissection, which may require dissecting cancerous tissue directly off these major vessels, or in very rare and extreme cases, resecting and grafting a portion of a vessel that is invaded by tumor.

Key Coding Information

  • wRVU (2024): 38.62
  • Assistant Surgeon Payable: Yes. This is a complex procedure often requiring an assistant. Modifier -80, -81, -82, or -AS may be appropriate depending on the payer and the assistant’s credentials.
  • Global Period: 90 days. This is a major surgical procedure, and all typical pre-operative and post-operative care related to the surgery is included in the reimbursement for this code.
  • MS-DRG: The MS-DRG is determined by the principal diagnosis, secondary diagnoses (CC/MCC), and the procedure performed. Common DRGs include:
    • MS-DRG 656-658: Kidney & Urinary Tract Neoplasms with/without CC/MCC
    • MS-DRG 715-716: Other Male Reproductive System O.R. Procedures for Malignancy with/without CC/MCC

CPT Code Tree

  • Hemic and Lymphatic System (38100-38999)
    • Excision (38300-38780)
      • Radical Lymphadenectomy (Radical Resection of Lymph Nodes)

Inclusions and Exclusions

Includes (Bundled into the code)

  • Laparotomy (abdominal incision) and exploration of the surgical field.
  • Mobilization of the colon, duodenum, and other intra-abdominal organs to access the retroperitoneum.
  • Ligation and division of the lumbar arteries and veins as necessary to perform the dissection.
  • Identification and preservation of the ureters, renal vessels, and other vital structures.
  • The complete dissection and removal of lymphatic tissue from the specified regions (celiac, aortic, pelvic).
  • Minor vessel repair.
  • Wound irrigation and standard closure of the abdomen.
  • Placement of surgical drains.

Excludes (May be billed separately if appropriate)

  • Nephrectomy (Kidney Removal): If a radical nephrectomy is performed for a primary renal tumor along with the lymphadenectomy, it should be coded separately (e.g., 50230). Modifier -51 or -59 may be required.
  • Orchiectomy (Testicle Removal): A radical inguinal orchiectomy (e.g., 54530) is the primary treatment for testicular cancer and is a separate procedure from the RPLND. It is typically performed at a different time. If performed concurrently for some reason, it would be separately reportable.
  • Bowel Resection: If the tumor has invaded the bowel, requiring a resection, this is a separate and distinct procedure and should be coded in addition to 38780.
  • Vascular Grafting: While the code description includes dissection of the great vessels, if a segment of the aorta or vena cava is resected and requires a complex repair with a graft, this may be separately reportable by a vascular surgeon using codes from the Cardiovascular section (e.g., 35206, 35226).
  • Laparoscopic/Robotic Approach: This code describes an open procedure. For a laparoscopic or robotic equivalent, refer to the unlisted code 38589 (Unlisted procedure, lymphatic system) and benchmark it to 38780.

Commonly Associated ICD-10-CM Codes

This procedure is almost exclusively performed for malignancy.

ICD-10 CodeDescriptionClinical ContextHCC Info
C62.91Malignant neoplasm of right testis, unspecified whether descended or undescendedThe most common indication for an RPLND. This is for a primary testicular cancer, often a non-seminomatous germ cell tumor (NSGCT), which has a high propensity for retroperitoneal spread.HCC 12: Testicular, Penile, and Other Male Genital Cancers
C62.12Malignant neoplasm of descended left testisSimilar to the above, specifying the laterality and descended status of the affected testis.HCC 12: Testicular, Penile, and Other Male Genital Cancers
C77.2Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodesThis code would be used as a secondary diagnosis to indicate that the cancer has already spread to the retroperitoneal lymph nodes, which is the reason for the extensive dissection.HCC 10: Lymphoma and Other Cancers of Blood and Bone Marrow
C64.1Malignant neoplasm of right kidney, except renal pelvisOccasionally, an extensive RPLND is performed for advanced Renal Cell Carcinoma (RCC) with significant nodal involvement. The primary procedure would be the nephrectomy.HCC 11: Bladder, Kidney, and Other Urinary Cancers
C86.3T/NK-cell lymphoma, nasal typeWhile less common, certain lymphomas or other cancers (e.g., paratesticular rhabdomyosarcoma) may require this extensive dissection for staging or therapeutic purposes.HCC 8: Metastatic Cancer and Acute Leukemia
Z85.47Personal history of malignant neoplasm of testisMay be used as a secondary diagnosis in post-chemotherapy RPLND, where the primary cancer has been treated but residual masses in the retroperitoneum need to be removed.Not an HCC code itself, but points to a history of an HCC-related condition.

Coding Scenarios & Examples

Example 1: Primary RPLND for Testicular Cancer

A 28-year-old male was previously diagnosed with a non-seminomatous germ cell tumor of the right testis and underwent a radical orchiectomy. Staging CT scans show multiple enlarged retroperitoneal lymph nodes suspicious for metastasis. The urologic oncologist performs an extensive open retroperitoneal lymphadenectomy, dissecting all nodal tissue from around the celiac axis, aorta, vena cava, and down to the pelvic brim.

Example 2: Post-Chemotherapy RPLND

A 35-year-old male with metastatic testicular cancer received several cycles of chemotherapy. Follow-up imaging shows a significant reduction in the size of his retroperitoneal masses, but a 4 cm residual mass remains. To remove this teratoma or residual cancer, the surgeon performs an extensive open RPLND. The dissection is difficult due to extensive scarring (desmoplasia) from the chemotherapy.

  • CPT: 38780
  • ICD-10: C77.2 (Secondary malignant neoplasm of intra-abdominal lymph nodes), Z85.47 (Personal history of malignant neoplasm of testis)

Example 3: RPLND with Nephrectomy

A 55-year-old patient is diagnosed with a large right-sided renal cell carcinoma with extensive involvement of the hilar and para-aortic lymph nodes. The surgeon performs a radical nephrectomy and a concurrent extensive retroperitoneal lymphadenectomy.

Note: Payer policies vary. Some might consider the lymphadenectomy component of 50230 to be inclusive of some of the work of 38780. Clear documentation justifying the “extensive” nature of the dissection beyond a standard regional lymphadenectomy is critical for getting both procedures paid.

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