A mastectomy is the surgical procedure to remove one or both breasts to treat breast cancer. During workup or the procedure, nearby lymph nodes in the armpit may be biopsied to determine if the cancer has spread. If positive, those lymph nodes are removed during surgical treatment (axillary dissection/lymphadenectomy). When breast removal is performed alone, it is known as a simple mastectomy and billed as one unit per side. A mastectomy with lymph node dissection is called a modified radical mastectomy and billed with a specific CPT code.
In this case, WellRithms received a professional bill for a triple mastectomy. The California surgeon billed for two simple mastectomies on the right, one simple mastectomy on the left, and a left axillary lymphadenectomy. Not only did this bill not make sense from an anatomical perspective, but billing separately for the lymphadenectomy was incorrect.
WellRithms verified through medical records and operative notes that the patient did in fact only have two breasts and an axillary lymph node dissection was performed. The provider had unbundled the radical mastectomy by billing separately for a simple mastectomy and a lymph node dissection. In addition, they billed for an additional (third) mastectomy. After review, they were paid for a radical mastectomy on the left, and a simple mastectomy on the right.