General Surgery Coding Alert

Question: When the surgeon removes lymph nodes during a partial mastectomy, may we report the mastectomy using 19160 and the lymph excision separately using 38745?


Kentucky Subscriber


Answer: 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, Axillary lymphadenectomy; complete) separately. Instead, you should use a single, combined code to report the work of both procedures.

CPT eliminated partial mastectomy with lymphaden-ectomy code 19162 for 2007 and has replaced it with 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrant-ectomy, segmentectomy]; with axillary lymphadenectomy).

Bottom line: For all claims after Jan. 1, 2007, you should report 19302 only for combined partial mastectomy lymphadenectomy procedures.

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 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.