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Port Charlotte, FL
Best answers
I've never coded a mastectomy before and I have a one here and I need some clarification. How do I know if it's radical or modified radical? The dr. did a total mastectomy w/ a sentinel node bx too so I came up w/ 38792 for the inj and 38525 of the node removal, however the mastectomy codes also include node removals too. He didn't remove the nodes from the same incision that he used to perform the mast, so I don't think this should be bundled but I'm not sure. Can anyone help????


Houston, TX
Best answers

Physician needs to indicate it on the operative report, the exact type of mastectomy.
For Mastectomy;simple, complete it would be 19303, don't forget to indicate LT or RT
Also see if the op-report indicates deep lymph node, then you can use 38525

Radical is: 19303-19306 Modified radical: 19307

19305-19307 the cpt 38525 is included

When you ask the doctor, ask him to clarify what type of mastectomy and if not noted on the op, ask him to make an adendum.
You contact me @ work (407)498-3718, I have some info I can share w/you on this or email me: lisa.demichael@scrmc.hma.org
Hope this helps