General Surgery Coding Alert

Question: The op report documents excision of the left upper-outer breast quadrant and a complete left axillary lymphadenectomy. Should we code this as 19301 plus 38745 because it is a complete lymphadenectomy?

Oklahoma Subscriber

Answer: You should not bill this case as 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) and 38745 (Axillary lymphadenectomy; complete).

Instead, you should code this as 19302 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy) because it is the most complete and specific code for the service described in the op note. You should use this code whether the surgeon performs a partial or complete lymphadenectomy with a partial mastectomy.

NCCI: The National Correct Coding Initiative bundles 38745 as a column 2 code with 19301, meaning you should not report these two codes together.

Avoid: Although you might be tempted to report your surgeon’s work in this case as 19305 (Mastectomy, radical, including pectoral muscles, axillary lymph nodes), that code would also be incorrect because the surgeon performs a quadrantectomy, not a complete mastectomy.