Partial Mastectomy and Lymphadenectomy

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January 23, 2014

Question:

We are discussing a recent case the surgeon submitted for coding review. She performed a “partial mastectomy with axillary lymphadenectomy.” It appears we have two choices. We could report the partial mastectomy (19301) and the axillary lymphadenectomy code (38745) or there is a code 19302, Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy). What do you recommend?

Answer:

Without seeing the operative report, we’d recommend CPT code 19302. This code represents both services and is considered a comprehensive code. Reporting both 19301 and 38745 would be considered unbundling.