# 19325 vs 19301



## codedog

I  was told to code this  as 19301, 38525, 19125 , not sure because  I dont see any margins issue . Am I missing something ?

PREOPERATIVE DIAGNOSIS:	Right breast cancer, high-grade DCIS.

POSTOPERATIVE DIAGNOSIS:	Right breast cancer, high-grade DCIS.

PROCEDURES PERFORMED:	Right breast lumpectomy with needle localization and sentinel node biopsy.


DESCRIPTION OF THE PROCEDURE:  Consents were obtained from the patient previous to surgery.  The patient did have needle localization as well as radiographic injections to the sentinel node prior to operation.

OPERATIVE FINDINGS:  The patient was brought to the operating theater.   was prepped and draped in a sterile fashion.  1 g of Ancef was given prior to skin incision.  Attention was first made towards the sentinel node.  Isoflurane blue was injected into the areolar area of previous incision.  Radiographically, the active node was found on the skin and through the skin an incision was made there.  Lymph node was dissected out using electrocautery and sent for frozen.  Frozen did come back as negative for malignancy.  Then attention was made towards the right breast lumpectomy.  Two wires were inserted at the previous surgery, the anterior wire was at area of suspicion for ultrasound and the posterior wire was in the microcalcification.  Each specimen was dissected out using a Harmonic scalpel, was sent for evaluation.  Hemostasis was excellent.  The incisions were then closed with a 3-0 Vicryl deep dermal sutures as well as 3-0 Vicryl subcuticular running.  Steri-Strips were applied.  The patient did tolerate the procedure well.  There were no complications.  All counts were correct x2.


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## BABS37

I always look for a marker or marking clip or localization clip to bill for 19125... I don't see it in this one so I wouldn't code it. Maybe I'm missing something?


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## codedog

What about the wire ?


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## kalbright

1st question was only plain xray used for localiztion?


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## BABS37

My surgeon documents the needle localization wire and what modality he uses, so like stereotactic ultrasound guidance, mammographic...

For yours, I keep looking at 19290 with 76942 for ultrasound guidance (Two wires were inserted at the previous surgery, the anterior wire was at area of suspicion for ultrasound and the posterior wire was in the microcalcification) and also I would also use 38792 for the injection procedure radioactive tracer for identification of sentinel node  (Isoflurane blue was injected ...Radiographically, the active node was found on the skin and through the skin an incision was made). 

Like I said, I'm still learning this and my documentation is slightly different. Would love to know what the answer is myself but hope this helps and is somewhat right.


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## BABS37

Also, it doesn't specify in the report the level of depth of the axillary tissue-so was trying to figure out the difference with 38500 and 38525...maybe you could help me with that? When he says, " Lymph node was dissected out " does that count as 38525? I was just reading the following info:

 For the sentinel lymph node excision, you will select either 38500 or 38525, depending on the depth of the node.

Clinicians divide axillary lymph nodes into three levels. Level II and III lymph nodes are always deep (38525). Level I nodes may be either deep or easily palpable (38500), depending on the individual patient. Deep dissection always includes superficial dissection through the same incision. To ensure accurate code selection, the American Medical Association (AMA) recommends surgeons to carefully document lymph node depth.

To illustrate proper coding, CPT Assistant provides an example of a lumpectomy with attention to surgical margins, plus removal of two superficial sentinel lymph nodes through a separate incision.

In this case, proper coding is 19301 (for the partial mastectomy) and 38500 (for the excision of superficial sentinel nodes). You would not report 19302 for the removal of two sentinel nodes, which requires complete axillary dissection.

Remember, there is no required number of nodes that the surgeon must address during sentinel node excision. “Code 38500 or 38525 may involve removal of only one lymph node or a number of lymph nodes, as determined by sentinel lymph node identification by the physician during the dissection or by palpation,” CPT Assistant notes.


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## codedog

I code for an ASC 38792 was done at Radiology , as far as  the lymph node  doctor says  its  deep. Now the lumpectomy I still  dont see the attention to margins, does anyone see this?


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## BABS37

Oh ok that makes sense for you for 38792  

I don't see where it talks specifically about the 'margins' to confirm what was done but it does specify  "Then attention was made towards the right breast lumpectomy"... I would send it back or wait for the path report- it should be documented in there. 

Partial Mastectomy (Lumpectomy)
A lesion or mass is excised from the breast, along with a margin or rim of healthy tissue, which is called "attention to adequate surgical margins." The operative report must contain documentation of this attention to margins; the diagnosis is most frequently a malignant tumor. Physician documentation of the title of this procedure can vary significantly; a partial mastectomy may also be known as a lumpectomy, quadrantectomy or segmental mastectomy. The mastectomy CPT codes were renumbered and reordered for 2007. Assign CPT code 19301, Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy) for a partial mastectomy procedure. Code 19302 should be assigned if the procedure includes excision of axillary lymph nodes (between the pectoralis major and pectoralis minor muscles and the nodes in the axilla) via a separate incision. It's important to note that CPT codes typically provide combination codes that include both the mastectomy procedure and any related lymph node excision. The ICD-9-CM procedure coding guidelines don't provide combination codes, so for the lumpectomy mastectomy procedure, both codes 85.23, Subtotal mastectomy, and 40.23, Axillary node excision, should be assigned if the service is provided on an inpatient basis.


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## codedog

Thanks for info  Brooke


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## codedog

Going with 19301


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