Breast Bx. with Excision of axillary lymph node

bethh05

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Post Op: 1)Suspicious palpable abnormality of right breast
2)Enlarged indurated right axillary lymph node suspicious for metastic disease

Procedures: 1)Right breast lumpectomy
2)Excision of deep right axillary lymph node

Description:
The patient was placed on the operating table in supine position. With adequate IV sedation, the right breast region was prepped and draped in the usual sterile fashion. Lesion was outlined with marking pen and the area was widely infiltrated with 1% Lidocaine. With adequate anesthesia, #15 scalpel blade was used to make a incision to the skin and subcutaneous. Palpable abnormality was resected hemostatically with the cautery. There was noted to be enlarged node a bit more superior and deeper. A segment of this was resected as well. This handed off as a separate specimen. Wound was irrigated and hemostasis was assured. The skin was then reapproximated with 4-0 undyed Vicryl subcuticular stitch. Benzoin and Steri-Strips were applied followed by sterile dressing.

Path:Right breast mass: Invasive ductal carcinoma, poorly differentiated
Lymph node, Right axilla: Positive for metastic invasive ductal carcinoma

The physician charged a lumpectomy, but I do not think the dictation supports that, also would the excision of the lymph node be a separate CPT I know it was excised through the same incision but since it is a separate lesion could it be charged? Thank you very much
 
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mad_one80

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YES...you can code the 19301 with the 38525 NOT the 38740/45 since there were no drains used/involved. but since he did note that they lymph nodes were excised as a separate specimen you can code the lupectomy and excision of deep axillary nodes!

btw, my docs dictate much more through than yours which makes it way easier to code for me...maybe you can have a talk with your doctors on how to dictate/detail his surgery performance?? just a sugguestion.
 
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