06-02-2023 Code Scope of Regional Lymph Node Surgery-regardless of results
Scenario 2023:
- Mammogram-showed nodule LUOQ breast & questionable nodule in left axilla
- Needle biopsy left breast (done Elsewhere) +DCIS
- FNA Left Axilla (done at my facility)-negative
- Lumpectomy, no nodes removed (done at my facility) followed by chemo, radiation, hormones
Question: How would you code the benign FNA of the Left Axilla?
- Surgical Diagnostic and Staging Procedure- 01 A biopsy (incisional, needle, or aspiration) was done to a site other than the primary site. No exploratory procedure was done.
- Scope of Regional Lymph Node Surgery-1 Biopsy or aspiration of regional lymph node(s)
- Do not code the negative FNA left axilla-just note in text
Answer: Scope of Regional Lymph Node Surgery-1 Biopsy or aspiration of regional lymph node(s)
Rationale: The patient was diagnosed on needle biopsy of the primary site of breast, there was a question of axillary node mets so that is why the patient had a needle biopsy of the axillary node done as part of the diagnostic and staging workup, therefore that needle biopsy is to be recorded as a 1 in Scope of Regional Lymph Node Surgery. When it is part of the diagnostic & staging work up a needle biopsy of a regional lymph node gets coded as a 1 in Scope of regional lymph node surgery field. It doesn’t matter what the outcome of that biopsy is, the coding of the 1 in scope of regional lymph node surgery is to denote that it was done…. Whether the biopsy was positive or negative is reflected in the regional lymph node examined/positive fields. It is important to follow the appropriate rules for each field, we can’t mix/match our instructions. The instructions for Surgical Diagnostic & Staging procedures tell you to only record positive procedures & it also goes on to say NOT TO CODE surgical procedures which aspirate, biopsy or removed lymph nodes in an effort to diagnose/or stage the disease in that field- we are to code those type of procedures in the Scope f Regional Lymph Node field.
So, at that point ignore the instructions for coding Surgical Diagnostic & Staging procedure & use the instructions provided for coding the Scope of regional lymph node surgery field which state Record surgical procedures which aspirate, biopsy, or remove regional lymph nodes in an effort to diagnose or stage disease in this data item. It does not mention whether the results or positive or negative, because for this field that is irrelevant information. Don’t mix/match instructions for different fields.
STORE
STORE- Surgical Diagnostic and Staging Procedures
• Only record positive procedures. For benign and borderline reportable tumors, report the biopsies positive for those conditions. For malignant tumors, report procedures if they were positive for malignancy.
• Do not code surgical procedures which aspirate, biopsy, or remove regional lymph nodes in an effort to diagnose and/or stage disease in this data item. Use the data item Scope of Regional Lymph Node Surgery [1292] to code these procedures. Do not record the date of surgical procedures which aspirate, biopsy, or remove regional lymph nodes in the data item Date of Surgical Diagnostic and Staging Procedure [1280]. See instructions for Scope of Regional Lymph Node Surgery [1292].
STORE Scope of Regional Lymph Node Surgery
• The scope of regional lymph node surgery is collected for each surgical event even if surgery of the primary site was not performed.
• Record surgical procedures which aspirate, biopsy, or remove regional lymph nodes in an effort to diagnose or stage disease in this data item.
1= Biopsy or aspiration of regional lymph node(s)