Mastectomies...Help!

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I am so confused :confused:

He calls this, "Bilateral mastectomy with right sentinel axillary node biopsy."

The patient was again identified and the site and procedure confirmed. The patient was then given general anesthetic. Operative sites were prepped and draped with sterile towels.

Both breasts were approached through transverse elliptical incisions. The one on the right tails off into the right axilla to allow for axillary exposure. Skin incisions were made using knife and electrocautery. Skin flaps were elevated superiorly and inferiorly using electrocautery throughout for hemostasis. The breast was removed from medial to lateral taking the pectoral fascia into the right axilla. The probe was utilized to identify the sentinel node without difficulty. The node was visible and easily removed using electrocautery and found to have a value of about 1400 units above background level. The node was submitted and called to me as negative. Attention was turned to close of the right mastectomy site. The site was irrigated. Skin flaps were then closed with interrupted subcutaneous Vicryl. The left breast was handled in an identical manner with the exception of the axillary node not being approached.

I found a great resource on advanceweb.com about the definitions of the different methods of mastectomy, but there is something about each one that doesn't fit.

19303 - Simple complete - Removal of all breast tissue along with a portion of skin and nipple through elliptical incision. All subcutaneous breast tissue removed via dissection of breast tissue from pectoral fascia and sternum.

19304 - Subcutaneous - Breast dissected from pectoral fascia and skin. Breast tissue removed but skin and pectoral fascia remain.

19305 - Radical - Dissection of breast, overlying skin, pectoralis major and minor, and axillary lymph nodes.

19306 - Modified radical (Urban) (extended simple) - Dissection of breast, overlying skin, pectoralis major and minor, and axillary and internal mammary lymph nodes.

19307 - Modified radical - As above but pectoralis major/minor spared

From the op note above, he dissected breast tissue, NOT skin (which is what is messing me up), pectoralis, and axillary node (single).

I was thinking 19305-50 plus 38525-RT, but I've looked at it for so long, I don't even think that is right. Help!
 

BEARDOG

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DO NOT use 19305-this is a radical mastectomy which includes removal of the pectoral muscles which by his op note he did not do. The muscles were left intact. I would use 19303 for the mastectomy portion and also be very careful about your selection of lymph node biopsy, i.e, 38500 vs 38525. I do not see any documentation to support a deep axillary node biopsy and without this you must should use 38500.

Understand that when a mastectomy is done, skin, per se is not removed. An incision is made and the while some skin is removed to accomplish the dissection around the incision the breast tissue is dissected off the muscle and up the the subcutanous tissue, leaving "skin flaps". The depth of skin flaps can vary from surgeon to surgeon. Did the surgeon use lymphatic mapping (that is a dye injection) to idenfity the lymph node in addition to the radioactive isotope. If he did (i did not see it in the body of the op note) you would also charge 38900.
Based on the information you have i would probably code it as:
19303-RT
19303-LT
38500

Please note some carriers want you to use the 50 modifer and make the bilateral mastectomies a single line item (19303-50). That would be something you would determine. I hope I have not added to your confusion.

Debbie
CPC, CGSC
 

gared111

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Don't forget the 38900 for lymphoscintigraphy (mapping of sentinal nodes), if/when performed.
 
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