AMA Provides Clarity on Breast Excision/Lymph Node Coding

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In CPT
September 29, 2008
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By John Verhovshek

The most recent CPT Assistant (vol. 18, issue 9, Sept. 2008) now clarifies that when a surgeon performs partial mastectomy with complete axillary dissection, you should report 19302 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy.

Partial mastectomy with anything less than a complete axillary dissection, however, will call for 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) and the appropriate lymph node biopsy code 38500 Biopsy or excision of lymph node(s); open, superficial or 38525 Biopsy or excision of lymph node(s); open, deep axillary node(s).

Partial mastectomy codes 19301 and 19302 both describe open excision of a breast lesion with “specific attention to adequate surgical margins,” according to CPT Assistant, as well as removal of “a larger amount of breast tissue … some skin … [and] lining over chest muscles below the tumor.”

Code 19302 also includes excision of lymph nodes between the pectoralis major and pectoralis minor muscles, plus the nodes in the axilla. The AMA stresses that 19302 includes removal of “all identifiable axillary lymph nodes,” while retaining the pectoralis musculature. If the surgeon resects the pectoralis musculature in addition to axillary lymphadenectomy, you should forego 19302 in favor of an appropriate radical mastectomy code, 19305-19307.

Often, instead of a complete axillary dissection, the surgeon targets one or more sentinel lymph nodes for biopsy during partial mastectomy. Sentinel node biopsy is a less-radical procedure than that described by 19302. As CPT Assistant explains, “The whole purpose of a sentinel lymph node dissection is to determine cancer staging without resecting all of the axillary lymph nodes.”

In such cases, you would report the partial mastectomy using 19301. For the sentinel lymph node excision, you will select either 38500 or 38525, depending on the depth of the node.

Clinicians divide axillary lymph nodes into three levels. Level II and III lymph nodes are always deep (38525). Level I nodes may be either deep or easily palpable (38500), depending on the individual patient. Deep dissection always includes superficial dissection through the same incision. To ensure accurate code selection, the American Medical Association (AMA) recommends surgeons to carefully document lymph node depth.

To illustrate proper coding, CPT Assistant provides an example of a lumpectomy with attention to surgical margins, plus removal of two superficial sentinel lymph nodes through a separate incision.

In this case, proper coding is 19301 (for the partial mastectomy) and 38500 (for the excision of superficial sentinel nodes). You would not report 19302 for the removal of two sentinel nodes, which requires complete axillary dissection.

Remember, there is no required number of nodes that the surgeon must address during sentinel node excision. “Code 38500 or 38525 may involve removal of only one lymph node or a number of lymph nodes, as determined by sentinel lymph node identification by the physician during the dissection or by palpation,” CPT Assistant notes.

13 Responses to “AMA Provides Clarity on Breast Excision/Lymph Node Coding”

  1. Lisa Mahoney says:

    What if the surgeon performs removal of sentinal nodes and then makes a decision after the pathology comes back at the same OR session to complete a mastectomy with axillary dissection can you bill for the sential node removal and the mastectomy code during the same session?

  2. Karen Maloney says:

    I would not code the removal of the sentinal nodes if an axillary dissection is subsequently performed.
    Documentation in the Operative report would determine if I code a Modified Radical Mastectomy procedure, or Mastectomy and Axillary Dissection separately.

  3. Barb Daigle says:

    I have an article from General Surgery News Dec. 2004 that states “when a sentinel node biopsy becomes the basis for a decision to perform lyphadenectomy , it is extremely important that the operative note reflect the decision process. In this situation, the sentinel node biopsy is billable with the Mastectomy, partial with axillary lymphadenectomy (19302).” The article states you would put a 59/51 modifier on the 38525 code.

  4. Rhona Lawrence says:

    As of today which is the correct way to code sentinel node biopsy with mapping, partial mastectomy…frozen section return of nodes positive so complete lymphadenectomy. Is it definitely 19302, 38792 and nothing else but that or is there still a bit of controversy on who is still accepting 19302, 38525-59, 38792? I need a definite answer please.

  5. Monica Rice says:

    How would you code – Axillary breast tissue, benign mass removal? No nodes involved.

  6. krisnemal says:

    Breast cancer :- Diagnosis:- Left breast superior outer quadrant with axillary tissue : Infiltrating ductal carcinoma NOS, modified Bloom and Richarson grade-3 with no nodal metastasis (0/19).
    Microscopic: Section from the breast tissue show an infiltrating ductal carcinoma which is partly autolysed composed of malignant cells arranged in the form of solid sheets, nests, cords (score 3) These tumer cells are moderately pleomorphic (score 2) with hyperchromatic nuclei and prominent nucleoli..Mititic activity is noted with a count of 21 mitoses per 10 HPF (score 3). Inflammatory and desmoplastic respose is seen the surrounding stoma.The uninvolved breast parancnyma shows fibrocysic change. The resection margin are free from tumour cell invasion. No obvious lymphovascular invasion is seen in the sections taken. There were 19 lymph nodes identified frm th attached axillary tail with no evidence of tumour deposits seen (0/19).

  7. sara struthers says:

    I understand that an ounce of prevention is worth a ton of cure, but the thing is that no one knows for sure just how far out we are from finding a cure. In the mean time though, I think it’s more important to focus on the tasks at hand – for instance, methods of treatment for those who already have it. Having survived breast cancer myself, I found it a little frustrating that there was this relatively huge amount of support for breast cancer research, and little for those who are currently suffering. It’s not that I don’t appreciate all these donation commercials and pink ribbon stickers for your car and what not, but those do nothing for the ones like me, who have already undergone treatment, and are now focusing on breast reconstruction and getting their lives back.

  8. ashley says:

    I underwent breast augmentation after I had a sentinel node removed, and I have to warn you that sometimes it’s better to pay a little bit more and go to a more reputable doctor. I’m not going to list his name because it’s not like a got an infection or was a victim of malpractice or anything – it’s just that he has a poor eye for his work, to put it mildly. If you really want to see what I mean (and have the constitution for this sort of thing) look at the breast augmentation before and after pictures. I understand that I am still recovering from the removal of the lymph node, but this is obviously a botched job here. I guess that’s what I get for getting the operation in Chula Vista.

  9. Monica Rojas says:

    How would you possibly code Excision of right axillary accessory breast without really having to consider coding it as a mastectomy??

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  12. Yvone Wolz says:

    What is the correct cpt code for sentinel node mapping, the surgeon is not injecting any dye. My surgeon was told to use 38792, but this only describes the injection and not the mapping. The 38900 describes the mapping but they are not injecting any dye? Can someone help?

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