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Deep axillary lymph nodes, superficial or deep?

  1. Default Deep axillary lymph nodes, superficial or deep?
    Medical Coding Books
    Does anyone have information regarding what entails deep vs superficial lymph nodes? I ran across some information, the following is what I have been going by, please let me know if that is correct or if you have additional info:38500 (superficial) suggest one or two superficial nodes and has a 10 day global period.38525 implies a more complicated procedure and has a 90 day day global period. Level II and III nodes are considered deep. Level I nodes can be deep or superficial depending on depth, patient habitus, and extent of required dissection." " dissections are divided into three levels, Lymph nodes adjacent to the axillary tail of the breast may be considered superficial and those lymph nodes into the axilla would be considered deep"." Look for indications in the documenatation that the lymph node dissection was below the fascia or under a muscle mass or bone to bill for excision of deep nodes, if not, you are stuck with coding superficial nodes, so stress the importance of detailed documentation to your physicians." IF THE SURGEON REMOVES BOTH SUPERFICIAL AND DEEP NODES, YOU SHOULD NOT REPORT BOTH 38500 AND 38525". source- http://codingnews.inhealthcare/hot-coding-topics/

    Please let me know if I coded the following surgery correctly:Rt Breast cancer- RT Lumpectomy with needle localization. Sentinel lymph node BX.
    Isosulfan blue dye 1% was
    infiltrated in the outer portion of the left breast along with the
    outer portion of the areola laterally. The breast, axilla, along with
    the upper chest were prepped and draped in usual sterile fashion. The
    circulating nurse had called a surgical timeout, listing the patient's
    name and procedure to be performed. All members of the operative team
    were in agreement with that statement. A transverse skin incision was
    made at the inferior aspect of the right axillary hairline.
    Dissection was carried down through the subcutaneous tissues. Using
    the Neoprobe and tracing blue lymphatics, there were 2 lymph nodes
    that measured approximately 6 mm each, immediately adjacent to each
    other, deep in the right axilla. The vascular supply to these lymph
    nodes was divided between clips. Once removed, there was one of lymph
    node that was stained blue and had ex-vivo activity of 21. The other
    lymph node immediately adjacent had ex-vivo activity of 84. Both
    lymph nodes were submitted for pathology, labeled sentinel lymph node
    biopsy #1 and sentinel lymph node biopsy #2. The lymph node with the
    greatest ex-vivo activity was labeled sentinel lymph node biopsy #1.
    There was no significant activity remaining in the right axilla after
    removal of the lymph nodes. The pathologist later reported these as
    both negative for evidence of metastatic disease. The wound was
    irrigated with saline. Hemostasis was strict. Marcaine 0.25% with
    epinephrine was infiltrated into the subcutaneous tissues. The
    subcutaneous tissues were approximated using interrupted sutures of
    3-0 Vicryl. The skin was closed using a running subcuticular suture
    of 4-0 Vicryl. Sterile towel was placed over the incision. A
    separate set of surgical instruments were used for the lumpectomy.
    Surgical team's gloves were changed. There was a guidewire exiting
    the outer portion of the right breast. A skin incision was made
    superior and medial to the exit site of the guidewire. Dissection was
    carried down through the subcutaneous tissues. The wire was brought
    into the wound. The breast tissue around the wire was grasped with an
    Allis clamp and a generous specimen dissected free using sharp
    dissection. Once removed, the specimen was submitted to radiology.
    The wound was irrigated with saline. Hemostasis was strict and
    achieved with electrocoagulation and also a few suture ligatures of
    3-0 Vicryl. Four clips were placed at the periphery of the
    lumpectomy. Marcaine 0.25% with epinephrine was infiltrated into the
    breast tissues along with the subcutaneous tissues. The subcutaneous
    tissues were approximated using interrupted sutures of 3-0 Vicryl.
    The skin was closed using a running subcuticular suture of 4-0 Vicryl.
    Dermabond was applied to both incisions along with sterile dressings.


    Thanks in advance!

  2. #2
    I will look in my books tomorrow, but I know for sure do not use 19125. Also, find out where the breast cancer was, upper-outer, central, lower-outer, etc. and code to that. I will get back to you when I getr to work.

  3. Default Reply
    The H&P states upper outer RT Breast:

    Mammograms April 5, 2011, showed a 1.1 cm ovoid
    mass in the upper outer right breast that was new when compared with
    previous films March 9, 2010. There were also additional bilateral
    subcentimeter nodules on mammograms. There were no spiculated
    lesions, microcalcifications or other characteristics of malignancy.
    Ultrasound showed a 10.8 hypoechoic nodule at 11 o'clock position in
    the right breast that corresponded to the mammogram lesion. There
    were also noted to be several bilateral cysts that corresponded to the
    other mammogram abnormalities. The patient underwent an
    ultrasound-guided core biopsy of the right breast mass May 26, 2011.
    The pathology report confirmed infiltrating ductal carcinoma, poorly
    differentiated. After discussion of treatment options, the patient
    has elected to proceed with a right lumpectomy and sentinel lymph node

    The path does not reveal the site, but it does say associated with previous BX site.

    Also when he does a lumpectomy with needle localization, I usually use 19125. This involves radiological marker/preoperative placement and if he just removes the wire specimen, but pays no attention to margins. Is there any particualr reason why I should't on this one?


  4. #4
    Code as

    FYI, if documented excisions of mass/clip with attention to margins, that warrants for 19301, 38525-58..lymph nodes were staged intraoperatively, sent for frozen specimen and came back no metastases.

    Last edited by surgonc87; 06-22-2011 at 10:21 AM.

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