38747

Abdominal lymphadenectomy, regional (Add-on code)

CPT 38747 is a surgical add-on code used to report a regional abdominal lymphadenectomy performed in conjunction with a primary intra-abdominal procedure. This specific code describes the radical removal of lymph nodes within the celiac, gastric, portal, and peripancreatic regions. It may also include the dissection of para-aortic and vena caval nodes depending on the extent of the disease and the surgical objective. This procedure is typically indicated for the management of malignant neoplasms of the upper gastrointestinal tract, pancreas, liver, and biliary tree where there is a high suspicion or confirmed presence of nodal metastasis. The surgeon performs a meticulous skeletonization of the major abdominal vessels, including the celiac trunk, common hepatic artery, and portal vein, to remove all surrounding fatty and lymphoid tissue. This radical approach is essential for accurate oncological staging (N-stage) and to achieve optimal locoregional control. As an add-on code, 38747 represents the substantial extra effort and technical complexity involved in performing a formal regional node dissection beyond the limited sampling typically bundled into primary resection codes. It should only be reported when the lymphadenectomy is extensive and regional, rather than simple node biopsies. The documentation must clearly outline the specific node chains harvested to justify the use of this intensive add-on service. Because it is an add-on code, it is not subject to multiple procedure payment reductions and must be listed in addition to the primary surgical resection code.

Clinical Indications

  • Malignant neoplasm of the pancreas (e.g., pancreatic adenocarcinoma)
  • Malignant neoplasm of the stomach (e.g., gastric adenocarcinoma)
  • Malignant neoplasm of the liver or intrahepatic bile ducts
  • Malignant neoplasm of the gallbladder and extrahepatic biliary tract
  • Metastatic disease to the regional abdominal lymph nodes
  • Staging for neuroendocrine tumors of the upper GI tract
  • Radical surgical treatment for duodenal or periampullary carcinomas

Procedure Steps

  1. The primary surgical procedure (e.g., pancreatectomy or gastrectomy) is initiated, providing the necessary abdominal exposure.
  2. The lesser omentum is opened to access the celiac axis and the superior border of the pancreas.
  3. The surgeon identifies and isolates the celiac trunk, common hepatic artery, and left gastric artery.
  4. Lymphatic and fatty tissue is meticulously dissected from the celiac axis and the origins of its major branches.
  5. The dissection continues along the portal triad, clearing nodes from the portal vein and hepatic ductal structures.
  6. Peripancreatic nodes are removed, often involving the dissection of the tissue along the superior and inferior borders of the pancreatic head or body.
  7. If indicated by the disease stage, the dissection is extended to the para-aortic and paracaval regions between the level of the diaphragm and the inferior mesenteric artery.
  8. Vessels are skeletonized while ensuring the preservation of essential arterial supply and venous drainage to remaining organs.
  9. The harvested lymphatic tissue is labeled by anatomical station and submitted for histopathological examination.
  10. Hemostasis is verified along the major vascular structures before proceeding with the remainder of the primary operation.

Coding Guidelines

  • This is an add-on code and must be reported in conjunction with an appropriate primary procedure code.
  • Common primary codes include 43286-43288, 43620-43634 (Gastrectomy), 47120-47130 (Hepatectomy), and 48140-48155 (Pancreatectomy).
  • Do not report modifier 51 with 38747, as it is an add-on code.
  • The code includes the removal of celiac, gastric, portal, and peripancreatic nodes; it is not for simple biopsy of a single node.
  • The phrase 'with or without para-aortic and vena caval nodes' means the code remains the same regardless of whether these specific retroperitoneal nodes are included in the regional dissection.
  • Documentation should specify the nodal stations removed to support the 'regional' and 'radical' nature of the service.
  • If the lymphadenectomy is performed laparoscopically, ensure the primary code is also a laparoscopic procedure or use the appropriate unlisted laparoscopic code if a specific one does not exist (though 38747 is specifically used in the context of open or applicable laparoscopic primary codes as defined by CPT).

Associated ICD-10 Codes