modified radical mastectomy with sentinel node biopsy

arsusott@msn.com

Just wondering if someone could shed some light on this question. I understand that if a patient has a simple mastectomy with sentinel node biopsy that we are to code both the 40.23 (2 Q 2002 CC)and 85.41 simple mastectomy (which doesn't include lymph nodes). The patient I am confused about came in had a sentinel node biopsy which came back positive and then had a modified radical mastectomy during the same operative episode. For this would it be coded only 85.43 since 85.43 included lymph nodes? Or would it be coded 85.43 and 40.23. It codes out to a higher DRG if both 85.43 and 40.23 are coded. Anybody have any insight?

Thanks in advance,
Angela Susott, CCS, CPC, CCDS

catladyrn

This is an old article, and it references CPT rather than ICD9 coding, but I think the principles are the same:

http://www.supercoder.com/articles/articles-alerts/gca/breast-procedure-faq-solutions-for-common-coding-dilemmas/

"The CCI edits do not apply when the biopsy is diagnostic, i.e., the biopsy leads to the decision to perform the larger procedure. If the results of a biopsy are positive, for example, the surgeon may perform a lumpectomy or mastectomy. In such cases the biopsy is not included in the lumpectomy or mastectomy and is separately payable. But if the surgeon – having previously performed a biopsy – plans to remove a malignant mass but wants a confirmatory biopsy, this second biopsy is a component of the larger procedure and may not be billed separately."

Probably the coders in the group know the answer off the top of their heads, though....

Renee

kshumpert

I am referring to my circulating days on this one. A sentinel node biopsy involves a radioactive solution that is injected. A device that locates the radioactive solution is then placed between the axilla and breast and locates the sentinel node. The sentinel node is take to pathology. If the sentinel node shows metastasis, it is believed that the lymph nodes following the sentinel node have metastasis. The sentinel node is the first lymph node in the chain. Therefore if the sentinel node is clear it is assumed the following nodes are clear. The modified radical mastectomy was performed due to the findings from the biopsy. Taking one node is not synonymous with the lymph nodes being excised with the mastectomy. I would code both. By coding both procedures, you are demonstrating the need for the removal of the lymph nodes.

Kathy Shumpert, RN, BSN

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

When something can be read without effort, great effort has gone into its
writing. ~Enrique Jardiel Poncela

NormaB

Okay. I'm not sure I have the scenario confirmed in my thought process so here's the way I would approach the case.

-if patient came in and had a sentinal node bx and it was (+) and patient then had rad/mast I would code both codes - the lymph node bx and the rad/mast

-if the patient came in for the rad/mast and they then did the sentinal node bx the bx would be considered part of the larger surgery and only the rad/mast code would be coded.

Other thoughts?

N.Brunson, RHIA, CCDS

kshumpert

The sentinel node biopsy is a tool to determine if a radical mastectomy is necessary. The sentinel node biopsy would completed be prior to the mastectomy. If the sentinel node was negative for metastasis, then a simple mastectomy would be performed. If I read your last statement correctly, the modified radical mastectomy performed first-there is no need for the sentinel node biopsy to be performed because the lymph nodes (including the sentinel) have already been removed with the mastectomy.


Kathy Shumpert, RN, BSN

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

When something can be read without effort, great effort has gone into its
writing. ~Enrique Jardiel Poncela

lspryszak

I found this mention in Coding Clinic:

Coding Clinic, Fourth Quarter 2009 Page: 73
New Codes Effective with Discharges: October 1, 2009
Other coding advice or code assignments contained in this issue Effective with Discharges: October 1, 2009

"Question:

A 77-year-old female was admitted to the hospital with a painful and rapidly enlarging right buttock mass. Initially, the mass was thought to be a boil or carbuncle. The provider diagnosed Merkel cell carcinoma. A radical excision of the skin lesion and sentinel lymph node biopsy were performed. What are the appropriate diagnosis and procedure code assignments?

Answer:

Assign code 209.36, Merkel cell carcinoma of other sites, for the Merkel cell carcinoma of the buttock as the principal diagnosis. Assign code 86.4, Radical excision of skin lesion, and code 40.11, Biopsy of lymphatic structure, for the procedures performed."

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The identification of the sentinel node is a diagnostic procedure (infusion of radioactive isotopes to identify which lymphatic chain is draining the neoplasm), but the removal of the nodes is a surgical procedure. So it sounds as though you would code both procedures.