Wiki Need Breast Lumpectomy w/Lymph node Dissection Help..

[wjensen]

Hello,
I need help with a surgery where our Dr does a Sentinel node biops, Lt lumpectomy and lymph node dissection, and during the surgery the pathologist comes back with the results of metastatic cancer. The Dr had sent in two sentinel nodes to pathology that he had obtained using dye. He injected isosulfan 1% blue dye which was infultrated around the tumor in the upper portion of the left breast and traced the blue lymphatics, using the neoprobe to find the sentinel nodes. He closed the excision using sutures.

A seperate set of instruments were used for the lumpectomy. He also created skin flaps at this time which were developed using electrocautery. Once removed the 9'Oclock margin was marked with a double suture. Sent the lump to Pathology. He resected free two margins, 9'oclock and 6 o'clock. Sutures were used to mark the new margins of resection.

When he received the results from the pathologist stating positive for metastic breast cancer, obtained from the sentinel nodes, he decided to re-open the incision in the Lt Axilla to do a standard axillary lymph node dissection removing level I and level II lymph nodes. ( I researched and found that there is also a level III lymph nodes but he did not say he took any level III lymph nodes. So does that mean he did not do a complete lymphadenectomy? )

He noted that he took care not to stip the axillary vein. Also the long thoracic and thoracodorsal nerves were identified and preserved. The intercostal brachial nerve was also identified and preserved. I am thinking of coding the following CPT codes given that he did not mention complete lymph node dissection :
15574 - Skin flaps V51.8
19301 - partial mastectomy, lumpectomy 174.4
38525 - 174.4
38900 - New code which bundles the 38792 dye code. 174.4
So if i use 38900 I cannot use the 38792. I am not sure which of those is the correct one..

Please... can anyone tell me if this seems correct? Also can anyone tell me if I am thinking correctly that his lymph node dissection is not considered complete since he didn't mention level III nodes?

Thanks so much in advance for your help! I can be emailed at Wanda.Jensen@OrlandoHealth.com

Wanda J.

 

[surgonc87]

code it as following

19302
38525-m-58
38900

19302 does not say complete, it says with lymphadenectomy
38525 was staged within the procedure, so 58 goes
38900 is a cross over code for 19302

38525 is debatable rather it should be reported with 19302 that describes lymph nodes already, but extra work was done, sent out to frozen section then presumed as is.

That is how I would code that

MS

 

[MLNURSE70]

38525 and 38900 are not the primary procedure in your scenario, but this procedure reads to have been done in order to determine the correct code for the mastectomy procedure which is staged and planned to occur following the frozen section. I may apply instead -59 modifier as a separate incision modifier to 38525 if the incision was made, LN harvested and then incision closed prior to the pathologist getting back to your surgeon regarding the mets as the mastectomy was planned to be the primary procedure with breast cancer being the working diagnosis for all procedures.