# Deep axillary lymph nodes, superficial or deep?



## Trendale

Hello,
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.

Coded:
19125-RT
38525-51-RT
38900-RT
174.9

Thanks in advance!


----------



## daharden

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.


----------



## Trendale

*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
biopsy.

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?

Thanks!


----------



## surgonc87

Code as

19125-m-Rt
38525-m-58
38900-m-51
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. 

MS


----------

