Please note this question was answered in 2010. The coding advice may or may not be outdated.
Question:
This patient presented with a large right popliteal lymphocele. The op note reads: The incision was made through the old scar in the distal thigh over the lymphocele and the lymphocele was entered. About 300 mL of lymphatic fluid was drained. The sac of the lymphocele, which was huge, was then dissected using the cautery and was removed. The 2 areas were identified where the most probable source of the leak. Both of these were also oversewn with 3-0 Monocryl suture. Meticulous hemostasis was obtained and the tissues were cauterized or oversewn. Once we had satisfactory and very dry wound, a 10 Jackson Pratt drain was placed. Part of the sac was obliterated using interrupted 3-0 Monocryl sutures. The remainder of the incision was closed in 3 layers with 3-0 Vicryl for subcutaneous tissue and fascia, and staples for the skin. The physician then proceeded to place a right fem-pop bypass via a separate incision site. I am not certain how to code the lymphocele excision. Would CPT 38308 support this procedure or would it be prudent to use the unlisted code CPT 38999 and which possible comp code?
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