General Surgery Coding Alert

Tip: Know when to include a lymph node excision code, or pay the price.

If youre reporting the wrong partial mastectomy code or leaving off a lymph node excision code because youre not identifying exactly what procedure the surgeon performed, you could be costing your practice almost $250 per procedure. Or, if you upcode when you shouldnt, you could be getting almost $250 more per procedure than you should be, which can lead to major audit concerns.

To choose the proper coding for these types of procedures, you need to dig into your surgeons operative notes. Follow these expert tips on how to decipher your surgeons documentation to ensure you choose the right code every time.

1. Choose 19301 For Partial Mastectomy

If your surgeon removes a lesion plus a significant portion of surrounding tissue, you may report a partial mastectomy (19301, Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]).

Your surgeons documentation should indicate that he performed a partial mastectomy, which is an excision of a mass or lesion, with biopsy of a node or nodes, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. There is no specific requirement as to how many nodes the surgeon biopsies; however, it is not all of the nodes, she adds.

Note: If the surgeon removes the lesion and only a small portion of surrounding tissue, the excision code (19120, Excision of cyst, fibroadenoma or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19300], open, male or female, one or more lesions) is more appropriate.

2. Partial Mastectomy Plus Node Excision = 2 Codes

Key: When you surgeon removes sentinel lymph nodes during the procedure, you will also report a node excision code, says Monika A. Liddle, CPC, CGSC, PCS, surgical coding coordinator for Martin Memorial Health Systems in Stuart, Fla. Youll choose 38500 (Biopsy or excision of lymph node[s]; open, superficial) or 38525 (& open, deep axillary node[s]) based on your surgeons documentation.

Surgical definitions of superficial and deep vary with surgeons but generally lymph node dissections are divided into three levels, says M. Tray Dunaway, MD,FACS, CSP, a surgeon, author, speaker, and coding educator with Healthcare Value Inc. in Camden, S.C. 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.

Pointer: Look for indications in the documentation that the lymph node dissection was below the fascia or under a muscle mass or bone to bill for excision of deep nodes, coding experts advise. If your surgeon doesnt document the dissection to get to the node, youre stuck with coding superficial nodes, so stress the importance of detailed documentation to your physicians.

Caveat: If the surgeon removes both superficial and deep nodes, you should not report both 38500 and 38525, Cobuzzi says. The deep excision (code 38525) includes any superficial node excision or biopsy when performed at the same setting though the same incision, says CPT Assistant.

Beware staged exception: Following some partial mastectomies (19301), the surgeon may return during the postoperative period to see if there has been any lymph node involvement and, if so, may choose to remove the nodes at that time. In such a case, you would report the lymphadenectomy as a staged procedure using 38745 (Axillary lymphadenectomy; complete) with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.

Monetary impact: If you overlook the lymph node excision code, you could be costing your practice either $120 (the unadjusted fee for 38525, 3.33 RVUs times the 2009 conversion rate of $36.0666) or $288 (the unadjusted fee for 38500, 7.99 RVUs times $36.0666).

3. Choose 19302 For Complete Axillary Dissection

Often, with partial mastectomy, the surgeon will perform an axillary lymphadenectomy to remove the lymph nodes between the pectoralis major and the pectoralis minor muscles. The surgeon may also remove the nodes in the axilla through a separate incision at the same time.

When this occurs, you should not report the mastectomy and lymphadenectomy (38745) separately. Instead, you should use a single, combined code to report the work of both procedures, Cobuzzi says.

Bottom line: You should report 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy,segmentectomy]; with axillary lymphadenectomy) only for combined partial mastectomy with lymphadenectomy procedures during the same operative session.

According to CPT Assistant (September 2008), code 19302 describes open excision of breast tissue and includes specific attention to adequate surgical margins surrounding the breast mass or lesion. In a partial mastectomy, a larger amount of breast tissue and some skin are removed with the tumor. This also includes removal of the lining over chest muscles below the tumor. The lymph nodes between the pectoralis major and pectoralis minor muscles and the nodes in the axilla are removed. All identifiable axillary lymph nodes are removed, while retaining the pectoralis musculature.

Important: Its vital to your coding accuracy -- and your practices reimbursement -- that you check your surgeons documentation. If you report 19301 alone instead of 19302, youre losing $250. The unadjusted national Medicare fee in 2009 is $548.93 for 19301 (15.22 RVUs times the 2009 conversion rate of $36.0666) versus $794.55 for 19302 (22.03 RVUs times the 2009 conversion rate of $36.0666).

Tip: If the surgeon also resects the pectoralis musculature along with the axillary lymphadenectomy, you should avoid 19302, and instead choose the proper code from the 19305-19307 set, the CPT Assistant article states.