Anesthesia Coding Alert

Question: The surgeon performed an axillary sentinel node biopsy in conjunction with a partial mastectomy. Which anesthesia code(s) should we bill?

North Dakota Subscriber

Answer: Remember that even if the surgeon performs multiple procedures during the encounter, you only report one anesthesia code. Check which anesthesia code(s) the surgical procedures cross to and submit the anesthesia code with the higher base value. Base your time unit calculation on the total amount of time for the encounter (including all surgical procedures).

In this situation, your choice is easy because both surgical codes 38500 (Biopsy or excision of lymph node[s]; open, superficial) and 38525 (Biopsy or excision of lymph node[s]; open, deep axillary node[s]) cross to anesthesia code 01610 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla). Code 01610 is worth five base units.

Even if the surgeon reports a code such as 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy), many experts recommend still reporting 01610 instead of the primary anesthesia choice of 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) because the procedure involves axillary lymphatics.

Bonus tip: Sentinel node biopsy is not the same as lymphadenectomy, and confusing the two could have direct effects on the accuracy of your claims. Read your provider’s notes carefully and request a copy of the surgeon’s notes if you have questions, to ensure you choose the correct anesthesia code.