Lumpectomy with Sentinel Lymph Node Biopsy

CPT 19301
Approach Open
Add-on / Variant CPTs
  • 38900 — Intraoperative identification of sentinel lymph node with injection of dye
  • 38525 — Biopsy or excision of lymph node(s) open, deep axillary node(s)
Preoperative Diagnosis:

Right/left breast carcinoma [invasive ductal/lobular carcinoma / DCIS]

Postoperative Diagnosis:

Same

Procedure Performed:

Right/left lumpectomy (partial mastectomy) with sentinel lymph node biopsy

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal / local with MAC

Indications:

The patient is a [age]-year-old female with [right/left] breast cancer [measuring ___ cm, located in the ___ quadrant] presenting for breast-conserving lumpectomy with sentinel lymph node biopsy. The risks, benefits, and alternatives including total mastectomy were discussed with the patient, and informed consent was obtained. [Wire/seed/SAVI SCOUT localization was performed preoperatively.]

Findings:

[A palpable mass / wire-localized / SAVI SCOUT-localized] lesion was identified in the [___] quadrant of the [right/left] breast. [___ sentinel lymph nodes] were identified with [isosulfan blue dye and/or gamma probe]. Sentinel lymph node frozen section was [negative / positive for metastasis]. Specimen margins were [assessed on intraoperative specimen radiograph / by palpation] and [appeared clear / required re-excision of the ___ margin]. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine with the ipsilateral arm abducted on an arm board. [Anesthesia type] was induced. A surgical timeout was performed confirming patient identity, procedure, operative site (right vs. left), allergies, and administration of prophylactic antibiotics.

[Sentinel lymph node mapping: Isosulfan blue dye (5 mL) was injected periareolar/peritumoral.] [Technetium-99m sulfur colloid had been injected by nuclear medicine the day of/prior to surgery.] The breast and axilla were prepped and draped.

An axillary incision was made at the hair-bearing skin of the lower axilla. The axillary contents were inspected with the gamma probe. Blue-staining and/or hot lymph nodes were identified — [___ sentinel node(s) were removed]. Each node was confirmed as hot (ex vivo counts > 10x background). Axillary background counts were measured after excision and confirmed to be < 10% of highest sentinel node count. The nodes were sent for frozen section — result: [negative / positive].

A curvilinear/radial incision was made over the tumor site in the [___] quadrant. [The wire/SAVI SCOUT device was used to guide excision.] Electrocautery dissection was carried through the subcutaneous tissue to the breast parenchyma. The tumor with a margin of surrounding breast tissue was excised with care to achieve a gross tumor-free margin on all sides. The specimen was oriented with [sutures/clips: long = lateral, short = superior, medium = medial / posterior]. Specimen radiograph [confirmed localization target removed / showed margin closest to tumor at ___]. [Re-excision of the ___ margin was performed and sent as a separate specimen.]

Cavity hemostasis was achieved with electrocautery. Oncoplastic closure was performed by reapproximating the breast parenchyma with [2-0 Vicryl] interrupted sutures to minimize deformity. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.

Complications:

None

Specimens:

Lumpectomy specimen (oriented) and [___ sentinel lymph nodes] sent to pathology

Estimated Blood Loss:

Minimal (less than 20 mL)

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** breast carcinoma
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** lumpectomy with sentinel lymph node biopsy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***

INDICATIONS: The patient is a .PTAGE-year-old female with *** breast cancer, *** quadrant. *** localization preoperatively. Informed consent obtained.

FINDINGS: *** lesion identified. *** sentinel nodes removed; frozen section ***. Specimen margins ***. *** margin re-excision.

DESCRIPTION OF PROCEDURE:
Supine, arm abducted. *** anesthesia. Surgical timeout — laterality confirmed.

Sentinel node biopsy: blue dye injected periareolar. *** blue/hot nodes removed; ex vivo counts confirmed. Nodes to frozen section: ***.

Axillary incision. Breast incision over *** quadrant. *** localized excision performed. Specimen oriented (long=lateral, short=superior) and sent for specimen radiograph: ***. *** margin re-excision performed.

Cavity hemostasis. Parenchymal closure with 2-0 Vicryl. Skin with 4-0 Monocryl.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Lumpectomy specimen (oriented) and *** sentinel nodes to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Positive Sentinel Lymph Node

Intraoperative frozen section of the sentinel lymph node(s) returned positive for [macrometastasis / micrometastasis]. [Per Z0011 criteria (cT1-2, 1-2 positive sentinel nodes, planned whole breast radiation): no axillary lymph node dissection was performed and the patient will be treated with adjuvant radiation.] [Alternatively: an axillary lymph node dissection (levels I-II) was performed, clearing the axillary contents from the axillary vein to the long thoracic nerve medially and the thoracodorsal nerve laterally.]

Oncoplastic Closure

Given the volume of tissue removed and the breast size, an oncoplastic closure was performed to minimize deformity. [A local tissue rearrangement / reduction mammaplasty pattern / therapeutic mammoplasty] was used to reapprox the breast parenchyma. The nipple-areola complex was repositioned as needed. Skin was closed with subcuticular sutures.

Palpable Mass — No Localization

The tumor was palpable intraoperatively. No preoperative localization was needed. The mass was excised by palpation guidance with a [1-cm] gross margin on all sides. The specimen was oriented and sent for radiographic and pathologic margin assessment.

Charting Tips
  • Specimen orientation must be documented explicitly — state the orientation convention used (e.g., long = lateral, short = superior, medium = medial) and that the specimen was submitted oriented for margin assessment. This enables targeted re-excision if margins are positive.
  • Document axillary counts quantitatively — state the ex vivo count of each sentinel node and the background count. 'Hot node removed' without counts is insufficient. The ratio confirms SLN identity.
  • For positive sentinel nodes, document the specific intraoperative decision-making (proceed with ALND vs. Z0011/AMAROS criteria for omission) — this is an evolving area of practice and your intraoperative decision must be explicitly supported in the note.
Billing Tips
  • Bill 19301 for partial mastectomy (lumpectomy, 9.88 wRVU, 90-day global). Use for any excision of breast lesion with margins. Oncoplastic closure does not change this code.
  • Bill 38900 as an add-on code for intraoperative lymphatic mapping and sentinel lymph node identification (2.44 wRVU). This is an add-on to 19301 and requires intraoperative injection of blue dye or radiocolloid with documentation of mapping.
  • Sentinel lymph node biopsy (38500-38530) is separately billable in addition to 19301 and 38900. Document number of sentinel nodes identified, hot/blue status, and pathologic result.
  • If immediate re-excision of margins is performed at the same setting, this may be billable as a separate service — check with your coding team as bundling rules vary by payer.
  • 90-day global period: oncology follow-up, radiation planning, and wound checks are bundled for the surgical fee. Radiation oncology and medical oncology bill independently.