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Breast help please

  1. #1
    Default Breast help please
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    The Dr is doing a Mastectomy 19301 and axillary excisional LN bx. He wants to bill 38740. This is a breif discription: Made a incision in the axilla , dissection was carried down to the axillary fat pad proper where a enlarged, suspicious node was identified. It was separated from surrounding tissue, lymphatics were isolated and ligated with titanium clips and the specimen removed, closed with 3-0 and 4-0 . I think it should be 38525, but what do them mean by deep.
    Thank you for your input.

  2. #2
    38525: The physician performs a biopsy on or removes one or more superficial lymph nodes. The physician makes a small incision through the skin overlying the lymph node. The tissue is dissected to the node. A small piece of the node and surrounding tissue is removed, or the node may be removed. The incision is repaired with a layered closure.

    38740: 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.

    I believe 38525 is correct in your case.

  3. #3
    Thank you, I thought so. He did not mention veins, vessels or a drain.

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