Lymphadenectomy Question

slwitt

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The physician has dictated: "The old transverse incision in the right axilla was reopened deep and through the subcutaneous tissue down to the fascia. The mass of lymph nodes were bluntly and sharply dissected free beginning at the axillary vein. I dissected inferiorly taking out the axillary contents, carefully avoiding the nerve to the latissimus dorsi muscle. I could not actually identify the nerve to the serratus anterior. Vessels were clipped and divided. The 7-French Blake drain was placed through a separate stab wound inferior to the incision."

The patient was diagnosed with Breast Cancer and the path on this report was positive for metastatic carcinoma in 8/19 Lymph Nodes. Focal Invasive carcinoma identified within fibrofatty soft tissue.

Would this be correctly coded as a Axillary lymphadenectomy; complete (38745) or better coded with Excision of Deep axillary nodes (38525)?

Thank you in advance for any advise.
 

ARCPC9491

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The physician has dictated: "The old transverse incision in the right axilla was reopened deep and through the subcutaneous tissue down to the fascia. The mass of lymph nodes were bluntly and sharply dissected free beginning at the axillary vein. I dissected inferiorly taking out the axillary contents, carefully avoiding the nerve to the latissimus dorsi muscle. I could not actually identify the nerve to the serratus anterior. Vessels were clipped and divided. The 7-French Blake drain was placed through a separate stab wound inferior to the incision."

The patient was diagnosed with Breast Cancer and the path on this report was positive for metastatic carcinoma in 8/19 Lymph Nodes. Focal Invasive carcinoma identified within fibrofatty soft tissue.

Would this be correctly coded as a Axillary lymphadenectomy; complete (38745) or better coded with Excision of Deep axillary nodes (38525)?

Thank you in advance for any advise.

I would use 38745 - it better describes what was done. Here's the description I get for it: The physician makes a diagonal incision across the lower axilla, exposing the axillary vein. The fatty tissue, lymph nodes, and vessels beneath the vein are dissected free. A drain is placed and connected to suction. The tissue and skin is closed with sutures.

38525 is just the lymph node biopsy, one or more, and he's doing much more than just that.
 

slwitt

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Thank you for your assistance, that was my first thought but it was the first time they have performed this procedure alone and I could not find a good description within my resources.
 
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