tci General Surgery Coding Alert - 2020 Issue Q4

Reader Questions: Beware Breast-Plus-Lymph Pitfall

Question: The op report documents excision of the left upper-outer breast quadrant and a complete left axillary lymphadenectomy. Should we code this as 19301 plus 38745 because it is a complete lymphadenectomy? Oklahoma Subscriber Answer: You should not bill this case as 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) and 38745 (Axillary lymphadenectomy; complete). Instead, you should code this as 19302 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy) because it is the most complete and specific code for the service described in the op note. You should use this code whether the surgeon performs a...

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