tci General Surgery Coding Alert - 2012 Issue 4

Reader Question: 38740: Reserve for Separate Surgical Procedure

Question: If the surgeon excises a breast mass from the lower inner quadrant based on a prior biopsy cancer diagnosis, and also removes two axillary lymph nodes through a separate excision, should we bill 19301 plus 38740? Michigan SubscriberAnswer: No, you should not report the service as 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy)] plus 38740 (Axillary lymphadenectomy; superficial). Do this: Instead, you should bill the service using the single most specific code -- 19302 (...with axillary lymphadenectomy). Although 38740 versus 38745 (... complete) allows you to indicate that the lymphadenectomy your surgeon performed was superficial...

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