Neck Dissection (Selective and Modified Radical)

CPT 38724 · 23.35 wRVU · 90-day global

CPT38724

wRVU23.35

Global90-day

ApproachOpen

ComplexityComplex

Add-on / Variant CPTs

38700 wRVU: 12.49 — Suprahyoid neck dissection (levels I–II only)
38720 wRVU: 21.4 — Radical neck dissection (all levels, SCM + IJV + SAN sacrificed)
38746 wRVU: 4.02 — Mediastinal lymph node dissection (add-on, thyroid/thoracic cases)

Preoperative Diagnosis:

[Papillary thyroid carcinoma with central compartment lymphadenopathy / squamous cell carcinoma of the [oral cavity / oropharynx / larynx] with clinically [N0 / N1 / N2] neck / melanoma of the head and neck with sentinel node positive / parotid malignancy]

Postoperative Diagnosis:

Same

Procedure Performed:

[Right / left / bilateral] [selective / modified radical] neck dissection, levels [I–V / II–IV / VI (central compartment)]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal with oral [or nasal] RAE tube. Intraoperative nerve monitoring employed.

Indications:

The patient is a [age]-year-old [male/female] with [diagnosis] presenting for [ipsilateral / bilateral / central compartment] neck dissection. [Preoperative staging: clinical T[X]N[X]M0.] [Neck dissection is performed for [clinically positive nodes / elective prophylactic dissection per institutional protocol / sentinel lymph node biopsy positive].] The risks, benefits, and alternatives were discussed including risk of injury to the spinal accessory nerve, marginal mandibular branch of the facial nerve, hypoglossal nerve, phrenic nerve, internal jugular vein, and carotid artery, and informed consent was obtained.

Findings:

[Levels II–IV / I–V / VI] were dissected. [X] lymph nodes were retrieved. [Positive nodes: matted / clinically positive / [X] palpable nodes.] The spinal accessory nerve was identified at the [posterior triangle / jugular foramen] and preserved throughout. The internal jugular vein was preserved. The sternocleidomastoid was preserved. [The marginal mandibular branch of the facial nerve was identified and preserved.] [The hypoglossal nerve was identified and preserved.] [The phrenic nerve on the anterior scalene was identified and preserved.]

Description of Procedure:

The patient was positioned supine with the neck extended on a shoulder roll and the head turned away from the operative side. General anesthesia was induced and the endotracheal tube was secured. Intraoperative nerve monitoring leads were placed and baseline signals confirmed.

The neck was prepped and draped in sterile fashion. A [transverse / hockey-stick / MacFee double horizontal] incision was made [along a skin crease one finger-breadth below the mandible extending posteriorly to the anterior border of the trapezius]. Subplatysmal flaps were elevated superiorly to the inferior border of the mandible and inferiorly to the clavicle.

[MODIFIED RADICAL NECK DISSECTION, LEVELS I–V:]
The dissection was initiated at the anterior border of the trapezius. The spinal accessory nerve (CN XI) was identified in the posterior triangle at [the point where it exits the posterior border of the SCM / Erb's point] and traced superiorly to the jugular foramen. The nerve was preserved throughout the dissection.

The dissection proceeded from lateral to medial. Level V (posterior triangle) contents were swept anteriorly. The SCM was [preserved / mobilized from its sternal and clavicular heads and retracted medially]. The internal jugular vein was [preserved / doubly ligated and divided at the clavicle and beneath the digastric].

Level IV (lower jugular) contents were dissected, taking care to protect the phrenic nerve on the anterior surface of the anterior scalene. The thoracic duct [on the left] was [identified and ligated / not encountered / was not injured].

Levels II and III (upper and middle jugular) contents were dissected along the IJV. The hypoglossal nerve (CN XII) was identified crossing the external carotid artery and preserved. Level IIA and IIB nodes were dissected around the SAN.

Level I (submandibular and submental triangles) contents were dissected. The marginal mandibular branch of the facial nerve was identified along the inferior border of the mandible and preserved. The submandibular gland was [included in the specimen / preserved]. The facial artery and vein were ligated and divided.

The specimen was passed off as a single oriented block, labeled with levels [I–V]. [A separate level VI specimen was sent if concurrent central dissection was performed.]

[CENTRAL NECK DISSECTION, LEVEL VI:]
The central compartment was entered by dividing the strap muscles in the midline. The prelaryngeal, pretracheal, and bilateral paratracheal nodal tissue was dissected from the level of the hyoid to the innominate artery. The recurrent laryngeal nerves (RLN) were identified bilaterally in the tracheoesophageal groove and preserved throughout, confirmed by nerve monitoring. The inferior parathyroid glands were identified and [preserved with intact vascular pedicle / autotransplanted to the [sternocleidomastoid / forearm brachioradialis muscle]]. The superior parathyroid glands were identified and preserved.

Hemostasis was confirmed. A [Jackson-Pratt / Blake] closed suction drain was placed in the [right / left / bilateral] neck. The platysma was closed with [3-0 Vicryl]. Skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.

Complications:

None

Specimens:

Right [left] neck dissection specimen, levels [I–V], oriented and sent to pathology. [Central compartment (level VI) sent separately.]

Estimated Blood Loss:

[X] mL

Drains:

[Jackson-Pratt drain in right/left neck, to bulb suction]

Disposition:

The patient was extubated in the operating room and taken to the PACU in stable condition. [Post-operative vocal cord mobility was assessed by laryngoscopy.] Drain output was monitored and the drain was removed when output was [<30 day]< ml span>.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left/bilateral *** neck dissection, levels ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General ETT; nerve monitoring

INDICATIONS: .PTAGE-year-old .PTSEX with *** presenting for *** neck dissection, levels ***. [CN+/N0 elective/sentinel+.] Risks including SAN, marginal mandibular nerve, RLN, phrenic nerve, IJV, and carotid artery injury discussed. Consent obtained.

FINDINGS: Levels *** dissected. *** nodes retrieved. [Matted/clinically positive nodes.] SAN identified and preserved. IJV preserved. SCM preserved. Marginal mandibular nerve preserved. Hypoglossal preserved. [RLN identified bilaterally, preserved.]

PROCEDURE:
Supine, neck extended, head turned. IONM leads placed, baseline signals confirmed. *** incision. Subplatysmal flaps elevated. [MRND Levels I–V: SAN identified posterior triangle, traced to jugular foramen, preserved. SCM preserved/retracted. IJV preserved. Level V swept. Level IV dissected; phrenic nerve preserved. [Left: thoracic duct identified/ligated.] Levels II–III: hypoglossal preserved. Level I: marginal mandibular nerve preserved; submandibular gland ***; facial vessels ligated. Specimen oriented, levels labeled, to pathology.] [Central (Level VI): strap muscles split midline. Prelaryngeal/pretracheal/paratracheal tissue dissected hyoid to innominate. RLN bilateral identified and preserved (IONM confirmed). Inferior parathyroids ***; superior parathyroids preserved.] JP drain placed. Platysma 3-0 Vicryl. Skin 4-0 Monocryl.

EBL: *** mL
SPECIMENS: Neck dissection levels *** to pathology [+ level VI separate]
COMPLICATIONS: None
DISPOSITION: Extubated, PACU stable. Vocal cord mobility *** post-op.

Signed: .ME, .MYDEGREE
.TODAY

Variants

Selective Lateral Neck Dissection (Levels II–IV)

A selective levels II–IV neck dissection was performed for [N0 oral cavity cancer / oropharyngeal cancer / thyroid cancer with lateral nodal disease]. Level I was not dissected given [no clinical submandibular involvement / primary site drainage not to level I]. The SAN was preserved. The IJV and SCM were preserved. Level V was not dissected. The procedure proceeded from level IV (lower jugular) superiorly to level II, preserving all named structures. Specimen labeled levels II, III, IV and sent to pathology.

Central Neck Dissection (Level VI) for Thyroid Cancer

Central compartment dissection was performed for [papillary thyroid carcinoma with clinically positive central nodes / prophylactic central dissection per institutional protocol / T3-T4 disease]. The bilateral paratracheal, pretracheal, and prelaryngeal nodal tissue was removed from the hyoid to the innominate artery. The RLNs were identified bilaterally in the tracheoesophageal groove and preserved; nerve integrity was confirmed with IONM throughout. The inferior parathyroid glands were identified; [glands were preserved in situ with intact vascular pedicle / devascularized glands were autotransplanted to the [right SCM / brachioradialis muscle] in small fragments confirmed viable by cut-surface bleeding]. Target yield: minimum 6 central compartment nodes for adequate staging.

Bilateral Neck Dissection

Bilateral neck dissection was performed for [bilateral clinically positive nodes / midline primary tumor with bilateral risk / bilateral central compartment disease after total thyroidectomy]. The right side was dissected first, followed by the left. Both IJVs were preserved; simultaneous bilateral IJV sacrifice risks cerebral venous hypertension and is contraindicated unless unavoidable. Bilateral thoracic duct awareness: the thoracic duct enters on the left; a right lymphatic duct may be present at the venous angle on the right. Both venous angles were carefully examined and any lymphatic channels were ligated.

Charting Tips

Identify and document all named neural structures by name. The minimum set for any neck dissection includes: spinal accessory nerve (CN XI), marginal mandibular branch of CN VII, hypoglossal nerve (CN XII), and the vagus nerve. For central dissection, document bilateral RLN identification and nerve monitoring confirmation. Postoperative nerve injury claims are the primary medicolegal risk; a note that names each nerve and states it was 'identified and preserved' is the standard of care.
Document parathyroid management in central neck dissection. Each parathyroid gland identified should be listed with its outcome: preserved in situ, devascularized and autotransplanted, or not identified. IONM-guided parathyroid preservation is emerging; document PTH if measured intraoperatively. Postoperative hypoparathyroidism is expected transiently; permanent hypoparathyroidism is a quality metric.
Document all levels dissected with total node count. NCCN requires documentation of the levels resected and the total lymph node count retrieved. Level-by-level node counts (e.g., 'Level II: 4 nodes, Level III: 6 nodes, Level IV: 3 nodes') allow accurate pathologic staging. Submit specimens in clearly labeled, level-specific containers.
Document thoracic duct identification on left-sided dissections. The thoracic duct enters the venous angle at the junction of the left internal jugular vein and subclavian vein. Inadvertent injury causes a chylous leak — document that the duct was 'identified and left intact' or 'identified and ligated for oncologic clearance.' Chyle leak is a common post-neck dissection complication and documentation of duct identification is standard.

Billing Tips

Modified radical neck dissection (MRND): 38724 (14.21 wRVU, 90-day global). This covers removal of cervical lymph nodes from levels I–V with preservation of at least one of: spinal accessory nerve (SAN/CN XI), internal jugular vein (IJV), or sternocleidomastoid (SCM). It is the most commonly billed neck dissection code for head/neck cancer with N+ disease.
Radical neck dissection: 38720 (15.55 wRVU). Use only when SAN, IJV, and SCM are all sacrificed. Document rationale for sacrifice of each structure (direct invasion, encasement, resectable disease). Radical is rarely performed today; most cases are MRND.
Suprahyoid dissection: 38700 (5.87 wRVU). Use for limited level I–II dissection (e.g., floor of mouth cancer, submandibular triangle). Rarely billed alone for oncologic neck dissection — document which levels were dissected.
Selective neck dissection does not have a dedicated CPT code. Bill based on the extent: levels I–V (functionally equivalent to MRND, bill 38724), limited level VI only (38724 with documentation), or suprahyoid only (38700). Some institutions bill 38724 for any selective dissection; document levels dissected explicitly.
Central neck dissection (level VI) for thyroid cancer: bill 38724 with documentation that central compartment nodes were dissected. Ipsilateral vs. bilateral central dissection should be specified. Add 38746 (4.02 wRVU) if concurrent mediastinal node dissection is performed.
Bilateral neck dissection: bill 38724 twice with modifier -50 (bilateral procedure) or as sequential procedures on the same day. Document each side separately in the operative note with independent findings.
When neck dissection accompanies another head/neck procedure (thyroidectomy, laryngectomy, parotidectomy), bill neck dissection with modifier -51. Each is separately billable. Document that neck dissection was a distinct, separately performed component of the operation.

ⓘ General Billing Tips →