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Charlene Posted Wed 11th of November, 2015 10:08:03 AM

What verbiage, other than deep, would indicate the biopsy was performed deep? What landmarks should I be looking for? I've researched Levels I, II and III nodes and all three are below the muscle.

SuperCoder Answered Thu 12th of November, 2015 04:51:33 AM

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.

Lymph nodes adjacent to the axillary tail of the breast may be considered superficial and those lymph nodes into the axilla would be considered deep"." Look for indications in the documenatation that the lymph node dissection was below the fascia or under a muscle mass or bone to bill for excision of deep nodes

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