tci General Surgery Coding Alert - 2019 Issue 3

You Be the Coder: Axillary Lymphadenectomy is Total

Question: The listed procedure on the op note is “partial mastectomy,” but the surgeon’s narrative includes a description of incising the axilla and removing superficial lymph nodes at level I. Should we code this as 19302? Iowa Subscriber Answer: No, you should not report this procedure as 19302 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy). That code describes a partial mastectomy with a total axillary lymphadenectomy, which would include both superficial and deep lymph nodes at levels I, II, and III. Instead, you should code the scenario as 19301 (Mastectomy, partial (eg...

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