tci General Surgery Coding Alert - 1999 Issue 5

Billing Comprehensive Lymph Node Excision With Biopsy

A general surgeon assists a colleague in a session involving lumpectomy and lymphadenectomy. After the procedure, the assistant surgeon receives a billing note from the primary surgeon, which the assistant needs to follow when he or she bills. The following operative report describes the procedure, which contains significant coding errors. The patient had a pre- and postoperative diagnosis of adenocarcinoma of the right breast. The procedures listed at the top of the op note included sentinel node biopsy of right axilla and right radical axillary node dissection with wide local excision or prior lumpectomy site of the right breast...

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