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E. maria Posted 6 Year(s) ago

I need your assistance with this op note.

1. Needle-directed right partial mastectomy
2. Needle-directed excision of fibroadenoma X2, right breast
3. Right axillay sentinel lymph node biopsy
4. Staged right axillary lymph node dissection.

Three localizing needles were noted in the medial aspect of the right breast and their course was inspected on the mammography. Sterile prep and drape was performed. The right axillary incision was made and extended down through the axillary fascia. There was blue staining of 2 seguences of nodes that were also positibe for radioactive counts and these were removed with the aid of cautery and were sent for pathological inspection. They later returned positive for metastatic disease and a standard axillary dissection was performed. Identifying the axillary vein, and sweeping all of the lymph node-bearing tissue infefiorly ligating venous tributary and dividing the intercostal brachial cutaneous nerves. The long thoracic and thoracodorsal nerves were identified and preserved throughout the dissection, and a clean dissection was performed due to the multiple small hard nodules that were present. All palpable abnomalities were removed and a 15-French Blake drain was placed through the inferior stab incision and towards the end of the case layered closure was done with 3-0 and 4-0 Vicryl and local anesthetic was placed to the drain into the dissection cavity to help her with postoperative pain control. Attention was turned to the breast while waiting for the pathologic results from the axilla and a periareolar incision was made along the medial and superior aspect of the areolar margin. Dissection was taken superficially, medially and superiorly to encounter the localizing wire seem to be going toward the subareolar region, but on mammography noting to be somewhat short of the targeted; however, there was quite bit of hardness to this area and so this area where a previous core biopsy had demonstrated an infiltrating ductal carcinoma, was addressed with a wide excision firt stating well medially through soft normal tissue and following a path of the guidewire to the firm tissue just medial tothe areola and then coursing underneath the areolar tissue and then somewhat deeper centrally. This excision was then oriented appropriately and sent for specimen mammography, which showed the target was acquired and then to pathology, where the margin was felt to be close on the anterior lateral aspect, which would be subareolar region and additional margin was excised and sent for permanent pathologic inspection. There was a large superior fibroadenoma which had been localized without penetration f the fibroadenoma, but this was able to be seen in the superior aspect of the wound via lumpectomy wound and was excised in its entirety and the guidewire was removed. Then the more superior and medial aspect, the alst guidewire was seen to be localizing about 1 cm presumed fibroadenoma and the guidewire was able to be followed down nicely to the adenoma which was excised. All bleeding points were controlled with cautery. Additional Marcaine was placed into the lumpectomy cavity prior to closure.

Should I code 19302 38525, 19125, and 19126? or 19301, 38745, 38525, 19125, and 19126?

SuperCoder Posted 6 Year(s) ago

The appropriate CPT code for the given case would be only 19302.
We can't report 38525 or 38745 separately as these Px are bundled into 19302.
Also can't report 19125 and 19126 separately, as Px 19302 is performed on the same lesions.

E. maria Posted 6 Year(s) ago

I am a little confused, per CPT, 19126 reads "each additional lesion separately identified by a preoperative radilogical marker" (list separately in addition to code for primary procedure) There were 3 lesions separately identified by preoperative radiological marker. Can you explain why is it we can't charge for the two additional marked lesions? My doctors said I should billed 19301, 19125, and 19126

SuperCoder Posted 6 Year(s) ago

I will prefer 19302 and 38525 here. Please look below CPT assistant article Sep 08 page 5.

Coding Brief:Partial Mastectomy/Lumpectomy and Axillary Lymphadenectomy-19301, 19302, 38500, 38525

Question #1: Would code 19301 (with the appropriate lymph node excision code), or code 19302, which includes axillary lymphadenectomy, be reported for the following clinical scenario: Lumpectomy with attention to surgical margins performed along with a separate incision in the right axillary area to remove two superficial sentinel lymph nodes?

AMA Response: Code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy), should be reported in addition to the sentinel node excision using code 38500. Partial mastectomy procedures describe open excisions of breast tissue and include specific attention to adequate surgical margins surrounding the breast mass or lesion. This also includes removal of the lining over chest muscles below the tumor. It is not appropriate to report code 19302 for the removal of two sentinel nodes, as a complete axillary dissection is required for code 19302. The whole purpose of a sentinel lymph node dissection is to determine cancer staging without resecting all of the axillary lymph nodes (code 19302) and potential lifelong consequences of lymphedema formation. With sentinel lymph node dissections, there is no required number of nodes that need to be excised. Sometimes only one node is sentinel.

To assist in ascertaining which lymph node excision code to report, the axillary lymph nodes are divided into Levels I through III. Levels II and III would always be deep (code 38525). Level I may be deep (code 38525) or superficial (code 38500), depending on the patient's body habitus. Superficial nodes at most sites would be easily palpable. Since Level I axillary lymph nodes may be deep or superficial, it is important that the depth (ie, deep or superficial) be documented in the medical record to ensure correct coding.

Sentinel lymph node biopsy involves removing the first node(s) in the lymphatic chain. To perform a sentinel node biopsy, the sentinel node must first be identified. A radioactive tracer and/or blue dye is injected into a region of a tumor (code 38792). The dye or tracer is then carried to the sentinel node (the lymph node most likely to be cancerous if the disease has spread from its origin by the lymphatic channels). The surgeon selects the likely area to look for the sentinel node. The node is usually axillary but may be in the internal mammary chain (code 38530). The sentinel node is identified by visualization of blue dye or by lymphoscintigraphy. It is removed and sent for frozen section pathology. If the surgeon determines that the sentinel node contains cancer, more lymph nodes may be removed and examined. If the node is negative for tumor, no further dissection is required.

In addition to the excision code, there is a code for injection of the dye or tracer into the tumor region, which is reported separately with code 38792, Injection procedure; for identification of sentinel node. When the nuclear medicine lymphoscintigraphy procedure is used to identify the sentinel node, code 78195, Lymphatics and lymph node imaging, is used for the lymphoscintigraphy. Note that the surgeon reports lymphoscintigraphy only if the surgeon performs it, which is typically the case. If a nuclear medicine physician directs the surgeon to the sentinel node, the surgeon would not report code 78195.

Question #2: What would qualify for axillary lymphadenectomy for code 19302? Is it more than five nodes, eight nodes?

AMA Response: Code 19302, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy, describes open excision of breast tissue and includes specific attention to adequate surgical margins surrounding the breast mass or lesion. In a partial mastectomy, a larger amount of breast tissue and some skin are removed with the tumor. This also includes removal of the lining over chest muscles below the tumor. The lymph nodes between the pectoralis major and pectoralis minor muscles and the nodes in the axilla are removed. All identifiable axillary lymph nodes are removed, while retaining the pectoralis musculature. A separate incision may or may not be required for the lymph node removal. A single incision may be used in the special circumstance where the breast lesion is lateral and the incision can be extended into the axilla. However, it is not the incision that makes the difference, but the extent of the axillary lymph node dissection. If the pectoralis musculature is resected in addition to axillary lymphadenectomy, this procedure would not be reported using code 19302; a code from the 19305-19307 set would be used instead.

On the basis of the physician's physical examination and other indicators about the likelihood that cancer has spread to the lymph nodes, the surgeon will generally remove between five and thirty nodes during a traditional axillary dissection. The key to selection is that all levels are evaluated, not the number of nodes at any level.

There are three levels of axillary lymph nodes (the nodes in the underarm or "axilla" area):

1.Level I is inferior to the lower edge of the pectoralis minor muscle.
2.Level II is deep to the pectoralis minor muscle.
3.Level III is superior to the pectoralis minor muscle.
For women with invasive breast cancer, this procedure often accompanies a mastectomy. It may also be done at the same time as a lumpectomy (code 19302), or after lumpectomy, in a separate session, following review of the lumpectomy pathology report (code 38525).

Question #3: What documentation would assist in choosing the appropriate code-that is, code 19302 versus code 19301 with code 38525?

AMA Response: Documentation in the operative report for code 19301 should indicate the partial mastectomy procedure performed. The procedures described by codes 19301, 38500 or 19301, 38525 involve excision of the mass or lesion with removal for biopsy of a node or node(s) (no specific number required for CPT reporting purposes). Code 38500 or 38525 may involve removal of only one lymph node or a number of lymph nodes, as determined by sentinel lymph node identification by the physician during the dissection or by palpation. Code 19302, however, requires a full dissection and is not a sampling of a few nodes even though there is no set number of nodes that must be removed to report 38500 or 38525. In selected patients, tumor staging uses the results of the ALND, or the procedure may be performed with a goal to reduce tumor burden. Patient history may also be useful. The purpose of sentinel node procedures or ultrasonicguided lymph node biopsy (often performed before the breast excision) is to reduce the need for ALND for diagnostic purposes. Therefore, patients who have had these procedures already are more likely to be receiving a full dissection. When an ALND follows a sentinel node biopsy during a breast excision, the sentinel lymph node biopsy is not separately reported. The injection procedure and scintigraphy (when used) for sentinel node identification (38792) is still reported separately.

Question #4: What type of documentation would support the reporting of code 19302? Which code is reported when the surgeon performs a lumpectomy, the tissue is positive, and now goes back to create greater margins and perform an ALND?

AMA Response: Documentation should include the partial mastectomy or lumpectomy (see Question #3 above) along with the intent and completion of a traditional axillary dissection. Returning to the operating room to perform an ALND and performing a minor incisional correction of the previous biopsy/resection site is not a breast excision, and the ALND is reported with code 38525.

Question #5: Is an ALND ever done through the same incision as the partial breast resection? If so, is this reported with code 19302 or code 19301 + 38525?

AMA Response: The same incision may be used as for code 19302 when the breast lesion is lateral and the incision can be extended into the axilla to perform a lateral lumpectomy and axillary lymph node dissection through the same incision. However, it is irrelevant whether the same or a separate incision is used in determining when to use 19302 as the key is whether the full dissection occurs. Again, it is not the incision that makes the difference but the extent of the axillary lymph node dissection.

Question #6: If both deep and superficial axillary nodes are sampled through one incision, are both codes 38500 and 38525 reported?

AMA Response: No, the deep excision (code 38525) includes any superficial node excision or biopsy when performed at the same setting though the same incision.

Posted by E. maria, 6 Year(s). There are 4 posts. The latest reply is from SuperCoder.

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