January 23, 2014
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?
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.