Wiki Please help...Modified Radical Mastectomy w/ sentinel lymph node removal

[pcorbisiero1231@comcast.net]

CPT 19303 & 38500???

DESCRIPTION OF PROCEDURE: The patient was placed in the supine
position and prepped with multiple coats of Betadine and draped
in the usual fashion. An elliptical incision was performed and
flaps were developed medially and superiorly as well as
inferiorly and laterally, and the breast was removed medially to
laterally. The sentinel lymph node was identified since 5 mL of
Lymphazurin was injected preoperatively and sentinel lymph node
was identified and removed. Hemostasis was achieved in the area
with fine Vicryl ties as well as electrocautery apparatus.
There were no enlarged palpable lymph nodes in the axilla. Two
1/4-inch silastic drains were placed and brought out inferiorly.
The wound was closed with skin clips. Dry sterile dressings
were applied. The patient was sent back to the recovery room in
good condition. Estimated blood loss was less than 50 mL.
Sponge, needle, and instrument counts were reported correct at
end of the case.

 

[cpc2007]

I would agree with CPT 19303 and 38500 based on this limited documentation. The mastectomy is simple (no mention of removal of chest wall muscles or lymphadenectomy in the axilla). The sentinel nodes are often located in the deep axilla which would be 38525 instead of 38500, but I cannot tell from this note how deep the nodes are to support the more extensive code. Another code often reported with a sentinel node biopsy is CPT 38900 which is for "mapping" the sentinel nodes (where they trace blue dye or heat from a radioactive tracer to locate and then remove the sentinel nodes). Again though he mentions the blue dye was injected before surgery but he doesn't clearly document following that blue dye to locate his sentinel nodes to qualify for mapping.

So again I would agree with 19303 and 38500 based on the limited note. These other codes and the documentation that would support them may be something to discuss with your physician if you have opportunity to do so. I hope that helps

Kim
www.codingmastery.com