General Surgery Coding Alert

You Be the Coder:

Axillary Lymphadenectomy is Total

Question: The listed procedure on the op note is “partial mastectomy,” but the surgeon’s narrative includes a description of incising the axilla and removing superficial lymph nodes at level I. Should we code this as 19302?

Iowa Subscriber

Answer: No, you should not report this procedure as 19302 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy). That code describes a partial mastectomy with a total axillary lymphadenectomy, which would include both superficial and deep lymph nodes at levels I, II, and III.

Instead, you should code the scenario as 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) and 38500 (Biopsy or excision of lymph node(s); open, superficial). Because the op note specifies superficial lymph nodes, you should avoid using 38525 (Biopsy or excision of lymph node(s); open, deep axillary node(s)).

The Correct Coding Initiative (CCI) edits do not restrict reporting 19301 and 38500 together. together.