modified radical mastectomy

mstanley

We got denied for a unilateral modified radical mastectomy with axillary sentinal node biopsy that was coded to DRG 581. The first procedure code was 40.11 and the second was 85.41. Was this coded incorrectly and is that why it was denied? Can someone help me? When I try to code it I came up with the first code as 85.43 and the second code 85.12 but I am not real sure. Thanks for any help you can give me. Martha

catladyrn

As far as I can tell, the coding was correct. Do you know that it was a coding issue? Was there an issue with the documentation to support an inpatient admission (I'm assuming it was an IP denial)? Did they give you a reason for denial?

Renee

Linda Renee Brown, RN, CCRN, CCDS, CDIP

ssalinas

It was coded correctly. The bx is grouped to the principal procedure by the grouper logic. 85.12 is biopsy of the breast.

Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336

ddouthit

Martha,

85.43 is correct code.

There is a coding clinic that addresses this scenario.

Sentinel node biopsy with modified radical mastectomy
      Coding Clinic, Second Quarter 2012 Pages:4-5 Effective with discharges: July 17, 2012

Coding Clinic, Second Quarter 2002, page 7, states "if the sentinel node is positive, a complete axillary node dissection is usually carried out." When a sentinel node biopsy is done followed by a modified radical mastectomy, should code 40.23, Excision of axillary lymph node, be assigned for the sentinel node biopsy, along with code 85.43, Unilateral extended simple mastectomy? A "simple mastectomy with excision of regional lymph nodes" is an inclusion at code 85.43.

Answer:

When a sentinel node biopsy and a modified radical mastectomy are performed during the same operative episode, assign only code 85.43, Unilateral extended simple mastectomy. In this case, the sentinel biopsy is not coded separately, because the modified radical mastectomy includes excision of regional lymph nodes. A modified radical mastectomyinvolves the removal of the entire breast, nipple/areolar region, including the axillary lymph nodes.

Sentinel lymph node biopsy is a diagnostic tool, in which one to three lymph nodes are removed for histopathologic evaluation. The biopsy is done to determine whether the malignancy has metastasized to the axillary lymph nodes. If the sentinel nodes are negative, the need for the more invasive "axillary dissection" is eliminated.

3M Nosology Help Message states:

The sentinel lymph node (SLN) is the first lymph node in a given lymphatic basin to receive fluid from a primary tumor site.

This node is usually the first to become involved by metastasis from a tumor. The sentinel node biopsy is an excision of a one to three lymph nodes. Many times the sentinel node is excised first for biopsy and if negative, then no further lymph node dissection is necessarily carried out.

It is not appropriate to report an ICD-9-CM code for a sentinel node biopsy that is performed prior to a radical/modified radical mastectomy carried out during the same session.

Hope this helps.


Dorie Douthit, RHIT,CCS
CDI Program/HIM
706-389-3364
St. Mary's Health Care System
1230 Baxter Street
Athens, Georgia 30606

ddouthit

Martha,

If it is a RAC denial that we agree with, we send to coding to correct codes and then coding notifies our Patient Financial Services that codes have been corrected. Coding does not submit a rebill. It then goes thru a RAC process on PFS(billing) side.
Hope this helps.

Dorie Douthit, RHIT,CCS
CDI Program/HIM
706-389-3364
St. Mary's Health Care System
1230 Baxter Street
Athens, Georgia 30606

mstanley

In this case RAC was not disagreeing with the coding. I was the one that questioned it. Recently I read an article that stated that sometimes medical necessity denials are in fact coding issues, so I have been checking the coding on all appeals I do. My big question now is can we correct coding post RAC audit if we find a mistake. Thank you for any help you can give me.