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19302 vs 19301 & 38525

  1. Question 19302 vs 19301 & 38525
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    does anyone have documentation stating how sentinel node biopsies are to be billed? If the surgeon removes 3 lymph nodes because they're blue, via a seperate incision but during a lumpectomy procedure (The injection would be billed with either coding option) my physician wants to bill a 19301 and 38525. These 2 procedures are worth approximately the same amount (within $50.00 of the Medicare allowed amount in Florida, after subtracting 50% for the second procedure) of CPT code 19302, so I feel that it's more efficient to bill 19302. From what I've sen in other posts on AAPC, you would bill 19302 for a lymph node resection done by seperate incision, but a 38525 if it's done via the same incision as the lumpectomy, but I can't find any documentation that supports that. I can't find any mention of lumpectomies in any Medicare LCDs, and everything I see on the internet is unclear or so old that it references deleted CPT codes.

    19302 doesn't specify a complete lymphadenectomy, and for 38525 you get paid the same amount regarless of the number of lymph nodes removed. I've been billing for surgeons for 4 years now and I haven't seen a single lumpectomy with complete axillary lymphadenectomy. It's either a full modified radical mastectomy or a lumpectomy with a few lymph nodes and the payment rates seem to back me up on that.

    Any thoughts?

  2. #2
    I'll add my thoughts. I think you are talking about partial not full mastectomy. I think you are saying 'full" I believe you know you mean partial. kk. Just so was are on the same page.

    I don't think axillary disections or bx's are done from the same incision in any of these situations, so that is no a determining factor. I would double check your path and op note, because with 3 blue nodes, the doctors might have done a complete axillary disection/ lymphadenectomy, which would definately put it in the 19303.

    Still if only three nodes were excised, I bet 19303 is a better representation of the work that was done, because of incision size needed, likely more visual inspections, eg.

  3. #3
    19301 is used for patients having a lumpectomy (or other partial mastectomy) only; 19302 is for lumpectomy with axillary lymph node dissection. 19303 would only be used for complete mastectomy, not lumpectomy and does not include excision of any lymph nodes, only the actual breast itself.

    The blue dye indicates that the patient has had an injection for sentinel lymph node identification and biopsy (most often done in the nuclear medicine dept). This is so that the surgeon can biopsy the correct node at the time of surgery and this is where the 38525 is used. Your physician is correct. If they are performing a lumpectomy with sentinel node biopsy the codes would be 19301 and 38525.

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