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Tumor Tip of the Week-Read the WHOLE op note to determine code

Scenario:

Surgeon Op Note:

Procedure(s): LEFT MASTECTOMY, SENTINEL LYMPH NODE BIOPSY, LEFT AXILLARY LYMPH NODE DISSECTION

Surgical Technique: Skin incision was made to include the area of retracted skin in an ellipse superior to the nipple.

Plastic Surgeon Note:

Procedure(s):1) RIGHT INTACT IMPLANT MATERIAL REMOVAL 2) TISSUE EXPANDER RECONSTRUCTION OF THE RIGHT BREAST. 2) LEFT BREAST RECONSTRUCTION WITH TISSUE EXPANDER.

3) DERMAL ALLOGRAFT FOR SOFT TISSUE REINFORCEMENT

Surgical Technique: Dr XXX proceeded to perform a left nipple sparing mastectomy and axillary node dissection.

Path Report:

[under gross description]

Type: simple mastectomy

Nipple: Not present

Question: What is the correct Surgery code?

  • 30 Subcutaneous mastectomy
  • 44 Total (simple) mastectomy without removal of uninvolved contralateral breast with Tissue Reconstruction
  • 45 Total (simple) mastectomy without removal of uninvolved contralateral breast with Implant Reconstruction

Answer: 30 Subcutaneous mastectomy

Reference:

STORE Appendix B30 Subcutaneous mastectomy A subcutaneous mastectomy, also called a nipple sparing mastectomy, is the removal of breast tissue without the nipple and areolar complex or overlying skin. It is performed to facilitate immediate breast reconstruction. Cases coded 30 may be considered to have undergone breast reconstruction.

SEER Appendix C Breast Surgery Codes- 30 Subcutaneous mastectomy A subcutaneous mastectomy, also called nipple sparing mastectomy, is the removal of breast tissue without the nipple and areolar complex or overlying skin. It is performed to facilitate immediate breast reconstruction. Cases coded 30 may be considered to have undergone breast reconstruction

Discussion: DO NOT CODE FROM THE DROP DOWNS IN YOUR SOFTWARE!!!  Refer to the manuals for valuable coding instructions, not available in the drop downs of your software. Also be wary of coding surgery from the title of the operation, read the entire operative note to determine what was done.  Sometimes the path report is also helpful in determining the tissue removed or as in this case not removed.

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