Bundle or Unbundle Lymph Nodes

How can you determine if lymph nodes should be bundled or unbundled when attached to a primary specimen?  This is determined by documentation of the pathology report and CPT guidelines.  There are certain specimens where lymph nodes will always be bundled with the primary specimen, but there are many case scenarios when nodes can be reported separately. 

By CPT definition, lymph nodes can never be unbundled for:

• 88309-Surgical pathology, gross and microscopic exam, breast mastectomy-with regional lymph nodes
• 88309- Surgical pathology, gross and microscopic exam, larynx, partial/total resection-with regional lymph nodes

This CPT bundling rule does not include Sentinel Lymph nodes. Separately identified & submitted Sentinel Lymph nodes will never be bundled with a primary specimen.  Sentinel Lymph nodes get an extensive workup, usually serial sectioning along with IHC staining usually looking for metastatic disease process.

There are other specimens when lymph nodes should be bundled. The CAP Today, October 1993, has stated when lymph nodes are an integral part of a resection specimen, they are not coded separately. For example, regional mesenteric lymph nodes removed with a colon resection or lymph nodes adjacent to the neck of the gallbladder are part of that resection. However, if extended lymph nodes from the periaortic region were submitted separately, these nodes would be separately reported. 

In addition, CAP Today, July 1999 “if lymph nodes are attached to the primary specimen and not separately identified they should not be separately coded for the lymph node exam.” This may apply to a liver specimen with attached hepatic, cystic and/or phrenic nodes, lung with hilar and/or intrapulmonary nodes, a pancreas with nodes or spleen.  However, if the lymph nodes are individually identified, microscopically examined, and separately diagnosed the nodes can be separately reported.  

Some common specimens that would not typically include attached lymph nodes would be cystectomy, nephrectomy, hysterectomy, prostatectomy and thyroidectomy and each regional lymph node dissection would be reported separately in addition to the primary specimen CPT.