Coding Lymph Node Excision, Biopsy and Lymphadenectomy

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June 23, 2016

Question:
During a lumpectomy, if the results of an axillary lymph node excision and biopsy (38525) lead to an axillary lymphadenectomy (38745), are both codes reported in addition to 19301, the lumpectomy?

Answer:
No, a lumpectomy with a deep axillary lymphadenectomy is reported with a single code, 19302, Mastectomy, partial (e.g., lumpectomy, tylectomy, quadranectomy, segmentectomy); with axillary lymphadenectomy. This code is valued for the lumpectomy and the axillary lymphadenectomy. The excision of lymph nodes for biopsy, 38525, is not separately reported as it is included in the total lymphandectomy.

*This response is based on the best information available as of 06/23/16.

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