Coding for a Mastectomy (New to Path Coding)

Farmington, MO
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I would just like a little clarity regarding when it is appropriate to bill the Axilla content and when it is not appropriate to bill the Axilla content with a Mastectomy. If I am correct when billing for a Mastectomy the Axilla content itself is included, however if the note states:

Right Breast Mastectomy, right Axilla content:
I would code as 88309 only???

New note different patient:

Left Breast Mastectomy, left Axilla Sentinel node:
I would code as 88309 plus the Sentinel node as 88307 / 88305 depending if it as a biopsy or a resection???
I do not believe it can be a resection when a Mastectomy is performed because the breast would be removed? I really don't know that for sure I am just assuming.

I have tried to find answers above per Google but I can not find very much regarding pathology coding. I feel that coding for pathology is like a secret society and there is no way to find the answers unless you ask a pathology coder and I do not know any so I thought I would post my question to this forum hoping that the pathology coders here could pleasssssse help me understand. I have decided I will code path even if I lose my mind doing it (LOL)

Thank you very much for your expertise!


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Yes, finding information on coding pathology can be challenging! If you or your employer can swing it, I highly recommend this coding resource for pathology: There isn't anything else like it for the comprehensive information and examples.

In answer to your questions about the specific cases, I'm a bit hesitant to give an answer without further details. Can you please share more of the pathology report?

For mastectomy cases, we need to pay attention to the type of mastectomy (partial, lumpectomy, simple, radical, etc.) and how/if the lymph nodes are examined.

Here are some BASIC guidelines:
88309: radical and modified radical mastectomy (which include regional lymph nodes), simple mastectomy with regional lymph nodes (sentinel nodes are separately charged). The inclusion of the axillary contents is key to choosing 88309
88307: Simple mastectomy without regional nodes, lumpectomy or partial mastectomy, sentinel lymph nodes (charged separately from the mastectomy)

Here are some links that might be helpful: