SLN bx (38500) & G8878

nlbarnes

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Hi ya'll - I will query the physician but I like to run things by people at times in case I have to have a comeback & I want to be prepared. She's charging 38500 & G8878. 1st, I'm good with the 38500, but I've never seen G8878 used before (The G codes are used to identify professional health care procedures and services that would otherwise be coded in CPT but for which there are no CPT codes.Please refer to your CPT book for possible alternate code(s)).

When reading the op report, I think there are a couple of unclear things that make me think there were 2 bx done, i.e., closing the wounds unless she's referring to the ampution closure. But I also can't justify 2 bx.

I will talk to the surgeon, I just wanted someone's input. Thanks!


DESCRIPTION OF PROCEDURE:
Pt had acral melanoma diagnosed of the dorsum of his left 2nd toe. The Breslow depth was
0.5 mm and it had 1 mitotic figure. Because of the mitotic figure, it
was felt that he would benefit from a sentinel lymph node biopsy.
Also, because he had a positive margin of melanoma in situ after the
1st excision, it was felt that he would benefit from a toe amputation.
Please see Dr. V's op report for the toe amputation

FINDINGS:
There was a significant signal from the radioisotope tracer in the
left inguinal region inferior to the inguinal ligament. There was
also a slightly less strong signal above the inguinal ligament, so
both areas were dissected. The only area that actually had a lymph
node that was positive with the blue dye as well as the radiotracer
was in the left inguinal region, so this was where the sentinel lymph
node was removed.

OPERATIVE REPORT:
I injected 3 mL for a total of 15mg of isosulfan blue. I massaged the area in the dorsum of the foot for 5 minutes. This was done prior
to Dr. V's amputation. After the injection, the foot was prepped and
draped in a sterile fashion and Dr. V's performed the amputation.
Dr. V was done, I went ahead and did my sentinel
lymph node biopsy procedure. I went ahead and identified the sentinel lymph
node with radioactive tracer before the area was prepped. The gamma probe
signal was strongest in the left groin region, inferior to the inguinal
ligament.There was also a lower signal in the left lower abdominal wall above the
inguinal ligament. This was also marked. I again used the gamma probe to identify the
spot with the highest counts again and this was still in the left inguinal
region inferior to the inguinal ligament. An incision was made tangential to
the lines of Tanner; this was done with an 15 blade. Electrocautery was used
to dissect down through the subcutaneous layers and the Geiger Counter was
used to identify the area of the strongest signal. A lymph node was
identified at the inferior aspect of the wound along the greater saphenous
vein. This was dissected free from the surrounding tissues and vascular clips
were placed to clamp off any blood vessels or lymphatic channels. There was a
clear blue lymphatic channel going directly into the lymph node. Once we had
excised this node, it was placed away from the operative field. The 10 second
count on this ended up being 944. We then checked the inguinal wound, and
this radioactive signal measured a maximum of 12. We, therefore, were
confident that we had the sentinel lymph node. The gamma probe was then used
to identify the area superior to the inguinal ligament. The counts came back
in the 150- 200 range. We went ahead and made a tangential incision just above
the left inguinal crease. Electrocautery was used to dissect down through the
subcutaneous layers.he gamma probe was then used to try to identify a source
of strong singal. The counts were still in the 100- 200 range, but they were
intermittent. I probed around throughout this area both superiorly and
inferiorly, laterally and medially, and there was no identifiable lymph node
and no identifiable blue dye in any area of this whatsoever. The external
oblique fascia was cleared and still there was no identifiable blue dye or
strong signal. Since the counts did not go up again and we had removed a
clearly labelled lymph node from the inferior aspect of the inguinal region,
we therefore determined that these counts were not reflective of any sentinel
lymph node in this area. I, therefore, irrigated both wounds with normal
saline and then I closed both wounds with interrupted 3-0 Vicryl suture and
closed the skin with a running 4- 0 Monocryl. Hemostasis had been achieved
with electrocautery and vascular clips were necessary.
 
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