# axillary sentinel node biopsy/excision



## BABS37 (Jun 5, 2012)

If a physician performs a sentinel node biopsy and waits in the OR to see what the specimen comes back as- then decides to perform an axillary dissection- seep tissue, can both be coded using a modifier 59? I know 38500 is superficial layer and the OP note only says 'flaps were elevated laterally to the surface of the axilla and from this point the axilla was entered and specimen was taken." 

Any thoughts? 

Thank you!


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## Grintwig (Jun 5, 2012)

In my opinion since the patient never left the OR I would only code the axillary dissection-deep tissue.


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## BABS37 (Jun 5, 2012)

Thank you!


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## Lujanwj (Jun 5, 2012)

I'd suggest to code for it with modifier -58.  The biopsy was the reason for the more extensive procedure.  You will use the reason you went to the OR for the DX (Mass?) on 38500 than the definitive DX (lymphoma?) from the frozen section as the reason for 38740/5.


NCCI Policy Manual Chpt 1

C. Medical/Surgical Package

4. A biopsy performed at the time of another more extensive procedure (e.g., excision, destruction, removal) is separately reportable under specific circumstances.
 ...

If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination. The biopsy is not separately reportable if the pathologic examination at the time of surgery is for the purpose of assessing margins of resection or verifying resectability. When separately reportable modifier 58 may be reported to indicate that the biopsy and the more extensive procedure were planned or staged procedures.


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## BABS37 (Jun 6, 2012)

Hi Lujanwj! I like your suggestion. I'm going to post the OP Note and see if I even have the right codes then because I think I was going to use 38525 for deep tissue but now I'm second guessing myself lol! Here it is: 

1. Left mastectomy, simple, closure
2. Dye injection for sentinel node biopsy
3. Left axillary sentinel node biopsy
4. Left axillary dissection- performed after awaiting the results of the sentinel node biopsy
5. Intermediate closure- 12cm length. 

The left chest and axilla were prepped and draped sterily. 2cc of methylene blue dye were injected in the retroareolar dermis and the breast was massaged for five minutes. An elliptical incision was marked out and incised. Flaps were elevated superiorly to the infraclavicular border medially, to the edge of the sternum and inferiorly to the inframmary crease, laterally to the surface of the axilla. From this point the axilla was entered. Neoprobe was used to guide dissection efforts and sentinel node, which was firm to palpation and without blue dye staining, was harvested and sent to pathology with a suspicion of a malignant diagnosis. This was returned on the frozen section as invasive cancer and therefore plans were made for an axillary dissection in light of those results. The breast was elevated now from the surface of the pectoral muscle, taking the pectoral fascia as well. The breast was separated from the atachments to the axillary fossa, marked with a short stitch superiorly and a long stitch laterally and placed in formalin and submitted to pathology. Axillary dissection was now begun following the pectoral muscle up to identify the axillary vein. The axillary contents were cleared off from the chest wall, identify and preserving the long thoracic nerve. The axillary contents were swept inferiorly from the axillary vein leaving the nodal tissue superior to the axillary vein in place. The thoracodorsal nerve, artery, and vein were identified and preserved as the remainder of the axillary contents were swept inferiorly off the subscapularis and latissimus. The remaining attachments were divided. The specimen was submitted to pathology. The wound was irrigated. Hemostasis was confirmed. 10 flat JP drain was placed over the pectoral muscle and one in the axilla. Both were secured. The wound was then closed in layers for an intermediate closure with inverted interrupted 3-0 vicryl in the dermis and running 4-0 monocryl subcuticular in the epidermis. 4-0 monocryl was run for a length of 12cm. Dermabond was applied and patient tolerated procedure well. 

I didn't code the intermediate closure as I think it's included but I was going to code it as: 
19303, 38792, 38500-59, 38525 but now I'm not sure what I need to do. What are your thoughts? 

Thanks for your help!


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## Lujanwj (Jun 6, 2012)

Take a look at 19307 38500-58 38900.  

Closures are never billable at the same time as a procedure because it's part of the Standard of Care per NCCI Policy Manual.  If you open, you've gotta close.  

Sentinel nodes are usually "superficial" as the deeper nodes are traced down from the sentinel node.  The Neoprobe was used for the Mapping -38900.  Be careful coding for the blue dye as it's not billable with 38792 anymore.  38792 specifically states "Radioactive Tracer" (probably injected by the radiologist) and 38900 includes the blue dye. 

Lastly, you would use -58 to unbundle the biopsy because it was staged (stage 1 38500, stage 2 19307).  In this case modifier -59 would indicate that the biopsy was of a different anatomical site (Lt vs Rt).

Hope that helps


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## Grintwig (Jun 7, 2012)

After reading the OP note I agree entirely with Lujanwj.


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