Separate Biopsy Coding Depends on Order of Events

As a general rule, do not separately report a biopsy and a planned tissue excision at the same location for the same session. Rather, the biopsy is bundled with the excision. For example, you would not separately report sentinel node biopsy (38500-38530) and planned lymphadenectomy (38700-38780) in the same region during the same operative session.

The exception to this rule is if the results of a biopsy prompt an excision. That is, no excision is planned, but a biopsy shows results that call for more tissue to be removed. For example, per National Correct Coding Initiative guidelines, “Sentinel lymph node biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy with or without lymphadenectomy.”

For example, if a surgeon performs a biopsy of the sentinel axillary node (38500 Biopsy or excision of lymph node(s); open, superficial) and, based on the results of that biopsy, several days later performs a partial mastectomy (19302 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy), you may separately report the sentinel node biopsy and the partial mastectomy.


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