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SEER Inquiry System - Report
Produced: 09/14/2024 12:19 AM
Question 20230067
Inquiry Details
References:
2023 SEER Manual, 173-176; 178-180. Scope of RLN Surg; Sentinel LNs Examined; Sentinel LNs Positive
Question:
First Course Treatment/Scope of Regional Lymph Node Surgery--Breast: How is Scope of Regional Lymph Node Surgery coded when initially there is a sentinel lymph node biopsy (SLNBx) and an intramammary node removed followed a month later by an axillary dissection for a right breast primary? See Discussion.
Discussion:
Patient has a diagnosis of invasive carcinoma of the right breast from a core biopsy on 04/2023.
Subsequent bilateral mastectomy and sentinel node biopsy proves one positive sentinel node and one negative intramammary node.
One month later there is a completion axillary node dissection with 15 nodes negative for malignancy.
Per previous SINQ 20190074, the initial mastectomy and sentinel node excision with intramammary node removal should be coded as Scope of Regional Lymph Node Surgery 6. It is unclear how the resulting axillary dissection should be recorded in Scope of Regional Lymph Node Surgery. There is no code for sentinel node biopsy and 3, 4, or 5 at same time (code 6) PLUS an additional subsequent axillary dissection.
Please provide coding instructions for Sentinel Lymph Nodes Positive, Sentinel Lymph Nodes Examined, and Scope of Regional Lymph Node Surgery in this scenario.
Answer:
Scope of Regional Lymph Node Surgery: Assign code 7, Sentinel node biopsy and code 3, 4, or 5 at different times. In this case, the SLNBx (code 2) preceded the regional node dissection (code 5: 4 or more regional lymph nodes removed), i.e., procedures performed in separate surgical events.
Sentinel Lymph Nodes Examined: Assign code 98, Sentinel lymph nodes were biopsied, but the number is unknown. In this case, only the results were provided.
Sentinel Lymph Nodes Positive: Assign code 01, Sentinel nodes are positive (code exact number of nodes positive). In this case, there was one positive sentinel node.
