I am running into an unusual situation with one of our breast surgeons and I would like some opinions on what others would do with this.
"The breast was prepped and draped in the usual sterile fashion. An incision was made in the axillary fold and dissected down through the axilary fascia. The gamma probe was used to guide the resection and three sentinel lymph nodes were identified. They were all hot and none of them were blue. The count measured 4436 for the first node, 4519 for the second node and 634 for a third node. The axillary basin count was 35 and they were all negative on intraoperative pathologic evaluation. The axillary cavity was irrigated and then closed in standard fashion."
Would you bill the 19301 or 19302? The rest of the note is complete and there are no questions, it is just the lymph node portion that is causing us to take pause. I am not giving credit for the lymph nodes and coding 19301 based on this documentation.
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