AMA CPT® Assistant - 2008 Issue 9 (September)
Partial Mastectomy/Lumpectomy and Axillary Lymphadenectomy-19301, 19302, 38500, 38525 (September 2008)
September 2008 pages 5-6 Coding Brief: Partial Mastectomy/Lumpectomy and Axillary Lymphadenectomy-19301, 19302, 38500, 38525 Although we previously addressed breast lesion excision with sentinel node excision and axillary lymph node dissection (ALND), the following questions offer further assistance when coding from medical record documentation. Question #1: Would code 19301 (with the appropriate lymph node excision code), or code 19302 , which includes axillary lymphadenectomy, be reported for the following clinical scenario: Lumpectomy with attention to surgical margins performed along with a separate incision in the right axillary area to remove two superficial sentinel lymph nodes? AMA Response: Code 19301 , Mastectomy, partial...
Subscribe or sign in to view the full article.
Article Overview
This article explains coding considerations for breast surgery and axillary lymph node procedures in the context of CPT Assistant guidance. It focuses on how operative documentation is evaluated for partial mastectomy/lumpectomy cases, axillary lymph node dissection, sentinel node procedures, incision approach, node depth, and related imaging or injection services. It is useful for coders, billers, and compliance staff who work with breast oncology and surgical pathology documentation.
Why This Topic Matters
Accurate reporting in breast and axillary surgery depends on matching the operative record to the documented extent of surgery and related services. This article helps readers understand the scope of guidance surrounding these commonly confused procedure combinations and associated documentation issues.
Article Sections
-
Coding Brief
Introduces the coding topic and frames the questions addressed in the article. Summarizes the overall focus on breast excision and axillary lymph node procedures.
-
Question #1
Addresses a lumpectomy scenario with sentinel node removal and discusses related coding considerations. Covers documentation issues tied to breast excision and lymph node assessment.
-
Question #2
Reviews what constitutes axillary lymphadenectomy for the procedure discussed in the article. Describes anatomical levels, operative extent, and documentation factors.
-
Question #3
Explains what documentation supports selecting between the principal breast and lymph node procedure options. Addresses the relationship between prior sentinel node procedures and subsequent dissection.
-
Question #4
Discusses documentation for reporting the more extensive breast and axillary procedure and related return-to-OR scenarios. Focuses on operative intent and completion as reflected in the record.
-
Question #5
Examines whether the breast and axillary components may be performed through the same incision. Clarifies the relevance of incision approach to the coding discussion.
-
Question #6
Addresses reporting when both deep and superficial axillary nodes are sampled in one setting. Focuses on how the procedures are characterized in the article's guidance.
What You Will Learn
- The general coding issues involved in partial mastectomy and lumpectomy cases
- How axillary lymph node procedures are discussed in relation to documentation
- How sentinel node identification services are presented alongside surgical excision
- What kinds of operative report details are relevant to breast and axillary coding
- How the article frames the relationship between incision approach and procedure extent
Who Should Read This
- Medical coders
- Coding auditors
- Billing professionals
- Compliance staff
- Breast surgery practice staff
- Oncology documentation specialists
Codes Discussed
Code Ranges Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com
