AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 1; Ask the Editor
Axillary Lymph Node Resection with Modified Radical Mastectomy
A 39-year-old patient with invasive ductal cancer of the right breast, status post neoadjuvant chemotherapy, underwent modified radical mastectomy of the right breast. During the axillary dissection, the provider removed level 1, level 2 and parts of level 3 lymph nodes. We assigned a code for the modified radical mastectomy of the right breast, but are seeking clarification of whether each axillary lymph node level is considered a separate body part (4th character), and therefore, multiple codes are assigned? ...
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Article Overview
This short coding guidance article discusses an ICD-10-PCS question involving breast cancer surgery with axillary lymph node dissection. It focuses on how the procedure is categorized at a high level, including body-part grouping concepts and whether separate codes are assigned for different axillary lymph node levels. The content is intended for facility coders and coding professionals working with operative reports for breast and lymph node surgery.
Why This Topic Matters
Accurate procedure coding for combined breast and axillary surgery depends on understanding how the procedure is represented in ICD-10-PCS. This article addresses a common question that can affect code assignment and consistency in inpatient coding.
What You Will Learn
- How this type of breast surgery is discussed in ICD-10-PCS coding terms
- How axillary lymph node anatomy is grouped for procedure coding purposes
- What kinds of coding questions can arise when lymph node levels are documented in an operative note
- How to interpret a coding query involving mastectomy and axillary dissection
Who Should Read This
- Inpatient coders
- Coding auditors
- Clinical documentation improvement specialists
- Coding educators
Codes Discussed
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