Coding Breast Diseases and Surgery

Vol. 17 •Issue 7 • Page 6
CCS Prep!

Coding Breast Diseases and Surgery

Part 1: Differentiating similar but related diagnoses and procedures can be a challenge.

Although treatment methods for breast cancer have improved over the years, a woman in the United States is now diagnosed with this disease every 3 minutes. That results in nearly 213,000 new cases of invasive breast cancer being diagnosed each year, along with almost 62,000 cases of non-invasive breast cancer. About 41,000 women in the U.S. die of the disease each year. For more information on the incidence of breast cancer, refer to the Web site:

Many women who are diagnosed with breast cancer, along with those with other breast disease processes, can be effectively treated now in an outpatient setting, although some procedures also may be provided on an inpatient basis. Understanding the differences between the various diagnostic and treatment options available is an integral skill for any coder. This article will cover diagnosis coding and diagnostic procedures related to the breast. Next month’s article will provide information on coding more extensive treatment procedures.

Diagnosis Coding

When assigning diagnosis codes for a patient with a breast disease, the coder must carefully review all information in the history & physical (H&P), procedure report, pathology or cytology report (if applicable) and any other pertinent documentation in the medical record. While it is an acceptable practice to assign diagnosis codes for only the information known at the time of the encounter, it’s generally recognized that data quality and completeness is greater if the final diagnosis at the conclusion of the visit is coded. For this reason, coders may be required to ensure that the final pathology, cytology or other diagnostic findings report is present before the final diagnosis code selection is made.

The majority of the benign breast diagnosis codes are located in categories 610 and 611–Disorders of Breast. The codes are differentiated primarily by type of disorder and it should be noted that all of these codes may be assigned for either male or female patients. Subcategory 611.7 contains signs and symptoms in the breast and the codes are useful in assignment of the first-listed (outpatient) or admitting diagnosis (inpatient). Two of the most common benign breast disorders are breast dysplasias and fibrocystic breast disease. Breast dysplasias can be generally defined as benign changes in the breast tissue. These changes may be associated with the menstrual cycle and hormonal fluctuations in the body. Terms such as fibroadenosis, cystic mastitis, benign breast disease, diffuse cystic mastopathy and fibrosclerosis of the breast may be used interchangeably in the clinical environment to describe fibrocystic breast disease, although ICD-9-CM provides separate classifications for specific terminology. Onset of symptoms is usually cyclical in nature, with a decrease in acuity after monthly menses begins.

Another commonly assigned code that is found in category 611 is gynecomastia, which is the abnormal development of breast tissue in a male. Onset can occur at any phase of life, depending on the underlying cause. Gynecomastia occurs when either the pectoral adipose or breast tissue hypertrophies or swells in response to systemic, hormonal or external stimuli.

When a breast lesion is documented as “malignant,” the coder must review the record for more specific information before automatically referring to category 174 (Malignant neoplasm of female breast). For instance, if the pathology report or other documentation indicates carcinoma-in-situ, code 233.0 should be assigned. Carcinoma-in-situ is defined as carcinoma that has not invaded neighboring tissue. These lesions are presumed to be precursors of invasive carcinoma but are considered to be local-ized and curable. If the neoplasm in-volves only the skin of the breast, code 173.5 or 172.5 (if melanoma is documented) should be assigned.

Also note that it’s possible for a woman to have multiple or bilateral breast masses that are determined to be malignant. In this instance it is acceptable to report multiple codes as long as those codes do not exactly duplicate one another. For example, if a patient is found to have breast cancer in the upper outer quadrant of one breast and the upper inner quadrant of the other breast, both codes 174.4 and 174.2 should be assigned. The coder should endeavor to locate the quadrant of the involved breast and report this level of specificity whenever possible. Refer to the illustration for more information related to breast quadrants.

In addition to codes for the neoplastic process itself, there are additional codes that should be assigned on breast carcinoma cases. A new category (V86) was recently developed that indicates whether the breast cancer patient is estrogen receptor (ER) positive or negative, which provides useful information for determining treatment options and prognosis. Seven out of 10 breast cancer patients have ER-positive tumors. Coders should also check the documentation carefully to determine whether the patient has any family history of breast carcinoma. If so, code V16.3 should also be assigned as a secondary diagnosis. Nationwide collection of this information helps researchers study patterns of disease incidence and develop treatment protocols appropriately.

Diagnostic Procedure Coding

In a significant number of cases, the diagnostic process for a patient with a suspected neoplasm (e.g., a lump was detected) is the mammogram. Mammograms may be considered diagnostic or screening. For more information on differentiating these services, along with their respective coding guidelines, refer to the CCS Prep! column from June 2006 titled, “Coding for Breast and Colon Cancer Screening Procedures.” It can be found on our Web site at

If there is a suspicious area, particularly one that appears to be a fluid filled cyst, the physician may elect to perform a puncture aspiration of the breast. This procedure involves the physician inserting a syringe needle through the skin of the breast into the cyst and fluid is evacuated, thus reducing the size of the cyst. Report code 19000 (Puncture aspiration of cyst of breast) for physician services or for a hospital outpatient encounter. If more than one cyst is aspirated, assign code 19001 for each additional cyst aspirated. Code 19001 is designated as an “add-on” code and should not be reported alone or without first assigning code 19000. If a breast cyst aspiration procedure is performed on an inpatient basis, code 85.91 (Aspiration of breast) should be assigned.

When a patient has a suspicious lesion of the breast, there are several options for obtaining a diagnosis. One less invasive option involves a fine needle aspiration (FNA) biopsy procedure. An extremely small (fine) needle, usually 22- or 25-gauge is inserted through the skin of the breast into the suspicious area and fluid or clusters of cells are removed for cytologic analysis. This service is most commonly performed in a physician office or clinic, and if the FNA doesn’t provide useful information, it may be recommended that the patient proceed to an incisional or excisional biopsy procedure. FNA services are reported with one of two codes, differentiated by whether imaging guidance was used to accomplish the procedure. Assign code 10021 (Fine needle aspiration; without imaging guidance) if no guidance was provided, and code 10022 (Fine needle aspiration; with imaging guidance) if the documentation indicates that some type of imaging guidance was provided (e.g., CT, ultrasound, fluoroscopy, MRI).

Other breast diagnostic procedures involving needle techniques vs. open or incisional techniques include needle core biopsies and services that utilize equipment such as an automated vacuum or rotating biopsy device. For a needle core biopsy, the physician inserts a large gauge needle through the skin of the breast and removes one or more “cores” of actual breast tissue. It’s important to note that tissue is involved in this procedure and the coder should ensure that she reviews a corresponding pathology report.

Again, the CPT codes for this service are differentiated according to whether imaging guidance was provided. Assign CPT code 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance) if there was no imaging guidance; assign code 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) if imaging guidance was provided. ICD-9-CM procedure code 85.11 (Closed [percutaneous] [needle] biopsy of breast) should be assigned for this service, regardless of the use of imaging guidance. CPT code 19103 (Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance) should be assigned when the documentation indicates that one of these devices, typically found in hospital radiology departments, was used during the procedure. ICD-9-CM procedure code 85.19 (Other diagnostic procedures on breast) should be assigned for this service if provided on an inpatient basis.

Other commonly performed breast biopsy procedures include incisional and excisional techniques. In an incisional breast biopsy the physician makes an incision into the breast near the site of the suspicious mass and a sample of the lesion is removed. Typically, the specimen is examined immediately and if benign, the incision is closed and the procedure concluded. However, if the lesion is found to be malignant, either the incision may be closed pending a separate, more extensive surgical encounter, or a more extensive procedure may be performed immediately. If another more extensive service is performed immediately, the code for the initial biopsy is not assigned. CPT code 19101 (Biopsy of breast; open, incisional) should be assigned for an incisional biopsy of the breast; the corresponding ICD-9-CM procedure code is 85.12 (Open biopsy of breast).

When a physician excises an entire tissue mass for biopsy reasons, it’s considered an excisional biopsy, but the CPT code for excision of breast lesion is assigned instead of a “biopsy” code. This is an important consideration because in many cases, the physician may document “breast biopsy” as the name of the procedure, when in fact, a breast lesion excision was actually performed. It’s essential that the coder carefully review the operative report to determine the extent of the procedure. CPT code 19120 (Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions) should be assigned. Note that the code may be used for either male or female patients and that the code should be assigned only once, regardless of the number of lesions excised through the same incision. According to CPT Assistant, April 2005, p. 13, if multiple separate incisions are made to remove multiple breast lesions, code 19120 may be reported more than once. Assign ICD-9-CM code 85.21 (Local excision of lesion of breast) for this service.

The other procedure that involves excision of an entire lesion is one that uses a localization technique, whereby a needle or clip is placed into the breast lesion preoperatively to assist in exact identification of the affected suspicious tissue. Assign code 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion) for the excision of the lesion that was identified with a radiological marker. Note that add-on code 19126 (each additional lesion separately identified by a preoperative radiological marker) is available when more than one needle or clip is used to identify more than one lesion. Note that a separate code for the placement of the localization device should also be assigned. These codes include 19290 (Preoperative placement of needle localization wire, breast), add-on code 19291 (each additional lesion) and 19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy). Coding staff in hospitals should ensure that the radiology department is not assigning these codes via the facility’s charge description master (CDM) before assigning them. ICD-9-CM codes 85.21 (Local excision of lesion of breast) and 87.37 (Other mammography) should be assigned for this procedure.

As a last reminder, coders should assign modifier RT (right side), LT (left side) or 50 (bilateral procedure) to all breast procedure CPT codes to ensure appropriate specificity. As with all CPT coding, coders should review any and all CCI edits and apply modifier 59 when appropriate.

Review your skills in coding breast diseases and diagnostic procedures with the following quiz:

1. A female patient with a suspicious lump in the upper outer quadrant of her right breast presented to the hospital’s outpatient surgery department for a breast biopsy. She was first taken to the radiology suite, where a needle localization wire was placed into the mass. The patient was then taken to the operating room, where the entire lesion and area surrounding the wire was excised, but there was no attention to obtaining clean margins. The pathology report showed intraductal infiltrating carcinoma and ER-positive tumor receptors. Assign the appropriate ICD-9-CM diagnosis, CPT and ICD-9-CM procedure codes; do not assign radiology CPT codes:

a. 174.9, V86.0, 19120-RT, 19290-RT, 85.12

b. 174.9, V86.1, 19125-RT, 19290-RT, 87.37

c. 174.4, V86.0, 19125-RT, 19290-RT, 85.21, 87.37

d. 174.4, V86.0, 19101-RT, 19295-RT, 85.21, 87.37

2. A 39-year-old female patient was seen in her physician’s office with a soft movable lump in her left breast. The patient’s mother was diagnosed with breast carcinoma in her early 70s. The physician used a 22-gauge needle for an FNA analysis of the breast. Fluid was aspirated and sent to the laboratory for analysis. The cytology report indicated no malignancy and the phy-sician informed the patient that she had fibrocystic breast disease. Assign the appropriate ICD-9-CM diagnosis, CPT and ICD-9-CM procedure codes; do not assign radiology CPT codes:

a. 611.72, 19100-LT, 85.11

b. 610.1, V16.3, 10021, 85.19

c. 610.1, V16.3, 19102-LT, 85.11

d. 610.0, V16.3, 10021-LT, 85.19

3. A 47- year-old female patient was sent to the hospital’s ambulatory surgery area when a right breast aspiration failed to yield any diagnostic information. She was seen in the radiology department, where a rotating biopsy device obtained a core of tissue, using CT guidance. The pathology report revealed only fibrosclerotic tissue, which the surgeon corroborated. Assign the appropriate ICD-9-CM diagnosis, CPT and ICD-9-CM procedure codes; do not assign radiology CPT codes:

a. 610.3, 19103-RT, 85.11

b. 610.0, 19100-RT, 85.11

c. 610.3, 19103-RT, 85.21

d. 610.0, 19103-RT, 85.19

Coding Clinic is published quarterly by the AHA. CPT is a registered trademark of the AMA.

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix, which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Answers to CCS Prep!: 1. c. The first-listed diagnosis should be 174.4, because the mass was located in the upper outer quadrant of the breast. The patient’s ER status was indicated as positive; code V86.0 should be assigned. The procedure involved excision of an entire lesion that was first identified by placement of a radiological marker. Code 19125 is most appropriate, followed by 19290 for the needle localization wire placement; both of these codes should have modifier RT assigned because the procedure was performed on the right breast. For the ICD-9-CM procedure codes, this was a local excisional procedure of a breast lesion; assign 85.21; code 87.37 is most appropriate for the needle localization wire placement. Refer to Coding Clinic, 3rd Quarter 1989, p. 17 for this guideline; 2. b. The physician indicated that the patient’s diagnosis was fibrocystic breast disease; code 610.1 is most appropriate. The patient has a family history of breast cancer (her mother); assign code V16.3 for this pertinent fact. The procedure involved a fine needle aspiration for cytological analysis and no imaging guidance was required. Assign code 10021 for the procedure. Note that no RT or LT modifier should be assigned to the FNA code because it doesn’t include designation of a paired body part in its description. For the ICD-9-CM procedure code, 85.11 (Closed [percutaneous] [needle] biopsy of breast) is inappropriate because it represents a core biopsy, whereby a core of tissue is removed. Code 85.19 is most appropriate; 3. a. The final diagnosis is fibrosclerosis of the breast, which is assigned to code 610.3. CPT code 19100 is not appropriate for the procedure because it was accomplished via use of a rotating biopsy device under CT imaging guidance. Code 19103 is most appropriate. ICD-9-CM procedure code 85.11 is most appropriate; 85.19 would only be assigned for an FNA and code 85.21 represents an open excisional procedure.

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