General Surgery Coding Alert

A general surgeon assists a colleague in a session involving lumpectomy and lymphadenectomy. After the procedure, the assistant surgeon receives a billing note from the primary surgeon, which the assistant needs to follow when he or she bills. The following operative report describes the procedure, which contains significant coding errors. The patient had a pre- and postoperative diagnosis of adenocarcinoma of the right breast. The procedures listed at the top of the op note included sentinel node biopsy of right axilla and right radical axillary node dissection with wide local excision or prior lumpectomy site of the right breast.

The op note described the procedures performed:

[or to the procedures performed at this time], the patient was sent ... to the radiology department where the isotope was injected around the primary biopsy site to facilitate the sentinel lymph node dissection ...

After this was completed, it was noted that the hairline was in the lower portion of the axilla. An incision was made beneath the axillary hairline. The skin and subcutaneous tissue were cut through. The pectoralis major muscle was next identified. Careful dissection revealed one of the lymphatics, which was blue in color, that entered into a blue lymph node. Two blue lymph nodes were readily identified and sent for sentinel node biopsy. ... The dissection was carried out. The tissue surrounding the axillary vein was identified and dissected free from the axillary vein laterally to the border of the latissimus dorsi muscle. Then the entire mass was removed from the chest wall and submitted for final pathological evaluation.

The next step involved reprepping and draping the patient using new gown, gloves and instruments. The prior biopsy site in the upper medial aspect of the right breast was next excised. An incision was made that involved the previous incision. Then the area surrounding the previous biopsy site was excised widely ...

The primary surgeon coded the procedure as follows:
38745 (axillary lymphadenectomy; complete)
38500 (biopsy or excision of lymph node[s]; superficial [separate procedure])
19160 (mastectomy, partial)

Note: According to the op report, the patient was sent to radiology to be injected with an isotope. That injection usually is done three to four hours before the main procedure is performed. A separate injection usually administered by the surgeon at the time of the procedure, not the isotope, makes the lymph nodes blue. Often, two separate injections are performed.

The only code the primary surgeon should have billed is 19162 (mastectomy, partial; with axillary lymphadenectomy), because only one lymph node removal can be billed and it already is combined with the excision of the prior biopsy site in the upper medial aspect of the patients right breast in 19162, says an Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist in North Augusta, SC.

The second lymphadenectomy could not be billed as a separate procedure because the surgeons always intended to remove the axillary lymph nodes and did not wait for the pathology report before removing them.

Nor can the excision of breast tissue be billed as 19120 (excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), male or female, one or more lesions); it is already included in the 19162. The assistant surgeon should bill the same code with modifier -80 (assistant surgeon) attached.

If the surgeons had excised the initial lymph nodes, waited for the frozen section report and then proceeded with the subsequent lymph node dissection, the second lymphadenectomy could have been billed with code 38525 (biopsy or excision of lymph node[s]; deep axillary node[s])not 38500with a -59 modifier attached (distinct procedural service). A separate report also would need to be dictated for the initial procedure.

Communication among surgeons offices is the key when assistant surgeons are involved because they need to work together to ensure correct billing. In this situation, the assistant surgeons coder should talk with the primary surgeons office to inform them that a corrected claim needs to be sent by the primary surgeon.

Note: In the new year, General Surgery Coding Alert will feature an article on coding for sentinal node biopsy.