CPT 49186 vs 38780: Coding retroperitoneal mass excision

My physician performed a retroperitoneal lymph node dissection (RPLND) to remove a 4-cm residual retroperitoneal mass after chemotherapy on a patient with testicular cancer. The physician told me to report Current Procedural Terminology (CPT) code 38780. But I think we should report CPT 49186. What do you think?

Jonathan Rubenstein, MD

Great question, and one that we have seen from a few others. CPT code 49186 is one of the 5 new CPT codes that are part of an updated code set (codes 49186-49190) that replaced CPT codes 49203 to 49205. These 5 new codes are used for reporting the excision or destruction of intra-abdominal primary or secondary tumor(s) or cyst(s) via an open approach. The actual descriptor is as follows:

Excision or destruction, open, intra-abdominal (ie, peritoneal, mesenteric, retroperitoneal), primary or secondary tumor(s) or cyst(s), sum of the maximum length of tumor(s) or cyst(s).

The code to be reported is based upon the summed maximal length of the tumor(s) or cyst(s) excised or destroyed. For example, code 49186 would be reported for excision of a tumor or cyst (solitary or summed) up to 5 cm. As per the code descriptor, this code should be used for the excision in the retroperitoneal space.

In contrast, code 38780 describes “retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure).” That is a procedure used to remove the lymph nodes from the retroperitoneum.

We believe the confusion comes from the typical lexicon surgeons use when performing surgeries, rather than the actual code descriptor and the procedure performed. Lymph node dissections typically involve removing a single (sentinel) or template (more extensive) group of lymph nodes, typically for diagnostic purposes. It is possibly therapeutic if there is a microscopic tumor in the nodes themselves. That is not the same as tumor/cancer removal if the cancer happens to be within a lymph node(s).

Mark Painter

Your question indicates that your physician performed “an RPLND (retroperitoneal lymph node dissection) to remove a 4-cm residual retroperitoneal mass after chemotherapy on a patient with testicular cancer.”It is unclear whether the procedure was truly an RPLND; this sounds more like a mass removal. We recommend that you review the operative note with the physician to determine the nature of the operation in terms of intent and performance. We suspect your discussion with the physician may reveal that the intended procedure was a mass excision, and 49186 would be correct. Even if the mass is a tumor within a lymph node, not only does the procedure performed match the descriptor, but ultimately it does not appear that the surgeon performed a lymph node dissection, because a lymph node dissection code is used to report the removal of lymph nodes (typically nonenlarged) for a diagnostic (or possible therapeutic) purpose. Many surgeons mistakenly call the removal of masses in the retroperitoneum a “lymph node dissection” procedure, when that is not actually what they are. If the physician removed the mass and it was medically necessary to remove the entirety of the retroperitoneal lymph nodes, CPT code 38780 could additionally be reported.