General Surgery Coding Alert

Question: When can we code separately for sentinel node biopsy with lymphadenectomy? Will the biopsy always be included in the more extensive exicision?

Alaska Subscriber

Answer: You should not separately report sentinel node biopsy (38500-38530) and planned lymphadenectomy (38700-38780) in the same region during the same operative session. Instead, you should include the sentinel node biopsy in the more extensive, planned, same-location lymphadenectomy.

Example: The surgeon performs a complete axillary lymphadenectomy (38745, Axillary lymphadenectomy; complete) to remove the lymph nodes between the pectoralis major and the pectoralis minor muscles. In this case, the complete lymphadenectomy automatically includes removal of any lymph nodes that would qualify as sentinel nodes (38525, Biopsy or excision of lymph node[s]; open, deep axillary node[s]). You should therefore report 38745 only.

If, however, the surgeon performs a sentinel node biopsy prior to an unplanned partial mastectomy (either with or without lymphadenectomy) -- and the subsequent excisions are a result of biopsy findings -- you may report the sentinel node biopsy separately.

"Sentinel lymph node biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy with or without lymphadenectomy," according to guidelines set forth in the introductory text of the national Correct Coding Initiative.

Example: The surgeon takes a biopsy of the sentinel axillary node (38500, -open, superficial). The pathology report indicates that the malignancy has spread, so the surgeon follows up several days later with a partial mastectomy with lymphadenectomy to remove the affected tissue.

Because the biopsy led to the decision to perform the mastectomy, you may report both 38500 and 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrant-ectomy, segmentectomy]; with axillary lymphadenectomy).