19301 & 38745 vs 19302

nlbarnes

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Resolved - after further review of the code descriptors & the op report, I'm going with 19302 as the lymph node dissection is a lymphanedectomy which is indicated with the pectoralis muscle.

I'm not confident about the 2 different ways of coding this. It seems that it's 19302 but the surgeon's never code it as such.

ROCEDURES:
1. Wire localization with lumpectomy of the upper outer quadrant of
the left breast.
2. Left axillary lymph node dissection.


OPERATIVE REPORT:
Once we were confident that we had at
least 1 cm margins around the area of the wire, we then dissected posteriorly
towards the chest wall. It did take
sometime to actually dissect all the way down to the posterior fascia. We then
excised the tissue in the superior, inferior, medial, and lateral aspects of
the breast all the way down to the posterior fascia. Some of the fascia was
excised after being grasped with Allis clamps. Once we had performed this
excision, the area in the upper outer quadrant was marked with vascular clips
in a circumferential fashion around the base of the cavity site. It was quite
large. Attention was turned to the axilla. The pectoralis fold was
identified as the medial margin and the marking pen was used to make a U
shaped incision at the inferior aspect of the axilla below the hairline. A 15
blade was then used to make an incision and the electrocautery was used to
dissect down into the subcutaneous tissue. A flap was raised superiorly and
inferiorly and laterally and medially. The medial border was the pectoralis
major muscle and then the lateral border was the latissimus dorsi muscle. The
clavipectoral fascia was then incised and the axillary fat pad was identified.
There was a palpable lymph node right on top of the axillary fat pad that was
quite firm. We then performed careful slow dissection around the
superior border of the axilla to identify the axillary vein. We identified
a very superficial branch of the axillary vein that was the
thoracoepigastric. We continued our careful dissection and we were
able to identify the long thoracic nerve immediately adjacent to the
chest wall and the serratus anterior. We then reflected the
pectoralis major muscle medially and started to remove the level two
lymph nodes. We also carefully dissected down the nodes from just
inferior to the axillary vein. We then identified the thoracodorsal
bundle inferior to the thoracoepigastric vessel. We then stayed along
the latissimus dorsi and went inferiorly to the apex of the axilla and
we also identified the intercostal brachial nerve that was carefully
dissected away from our axillary contents. Once we had carefully
identified the long thoracic and made sure that it was out of our
field as well as the thoracodorsal nerve, we then went ahead and
clamped the thoracoepigastric vein that was very superficial and
clipped it with three clips proximally, and one distally, then divided
it with the Metzenbaum scissors. We removed the axillary contents and
there were several palpable lymph nodes in this group.
 
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