Coding Breast Procedures Can Be Confusing

Vol. 15 •Issue 4 • Page 10
Coding Corner

Coding Breast Procedures Can Be Confusing

Procedures of the breast can be very confusing to coders. Physician documentation oftentimes does not use the same terminology as the code descriptions. In this article we will try to shed light on some of this confusion.

Several codes now exist for breast biopsies depending upon the technique the physician used. Needle core biopsy (19100 or 19102) describes the technique whereby a needle is used to extract tissue from the mass. Typically, there is no incision performed. Incisional breast biopsies (19101) are ones in which the physician takes a wedge or piece of the mass but not the entire mass.

In an excisional breast biopsy (19120), the physician removes the entire mass and may or may not use a preoperative radiological marker to identify the tissue to be removed (19125-19126). A pre-operative radiological marker may be blue dye, radioisotope or a needle localization wire—the most commonly used. Placement of the wire is assigned to codes to 19290—19291, depending upon the number of wires inserted. These wires may be placed before the procedure in another facility or in the radiology department before the patient presents to the operating room.

In dictation, physicians may also use the term “lumpectomy” when referring to excision of mass. In the CPT system, lumpectomy is assigned to code 19160, which describes a partial mastectomy (the excision of the lump or mass) in addition to adequate margins around the lump or mass. If the documentation is confusing as to whether the physician is performing an excision of a breast mass, cyst or lesion as opposed to a lumpectomy, query the physician for clarification.

Operative Report

Preoperative Diagnosis: Left breast mass; skin tags left axilla

Postoperative Diagnosis: Fibrocystic changes of left breast with fibroadenoma and focal sclerosing adenosis; squamous papilloma (skin tag)

Procedure Performed: Biopsy of left breast; removal of axillary skin tags

Anesthesia: Attended local

Indications for Procedure: On mammography, this 41-year-old woman was found to have a mass in the left breast, which was confined as being a solid area (on ultrasound) and located at about the 11 o’clock position. She has had no previous biopsies or masses or a family history of breast carcinoma. Options were discussed with the patient, and we decided to go ahead with the biopsy. X-ray localization will be performed in the radiology department. The risks and rationale of this wire were discussed, and she consented to the procedure.

Operative Technique: The area was prepped and draped in the usual fashion. Under satisfactory local Xylocaine anesthesia, a curved incision was made central to the site of the wire placement after infiltrating 1% Xylocaine with Epinephrine into the area. The wire was brought out into the wound, and a lobule of breast tissue was grasped along with the wire. All of the tissue down to the end of the wire and a bit beyond was excised including some more superficial areas where the lesion appeared to be located. This was removed, and hemostasis was accomplished with electrocautery. An additional small nodule, which appeared to be perhaps a fibroadenoma projecting into the space of the cavity after the tissue had been excised, also was excised. A J&J drain was brought out through a separate stab wound. The subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with stainless steel staples.

Sponge, instrument and needle counts were correct during closure of the wound and the patient tolerated the procedure without complications. At the site of the larger of the skin tags, 1% Xylocaine was infiltrated. The tags were clipped off, and the base cauterized. Clipping and cauterization of the additional three small tags also occurred. The patient left the operating room in satisfactory condition and was take to the recovery room.

Code Assignments and Rationale

ICD-9-CM Diagnosis Codes:

610.1 Diffuse cystic mastopathy

217 Benign neoplasm of breast

610.2 Fibroadenosis of breast

216.5 Benign neoplasm of skin of trunk, except scrotum

The physician identified that the patient has fibrocystic changes of the breast. In the ICD-9-CM manual index under fibrocystic, you will see an entry for breast, which leads to 610.1, diffuse cystic mastopathy.

The physician also identified focal adenosis of the breast. Check the term adenosis, and you will find a secondary index entry of breast (sclerosing), which leads to 610.2 (fibroadenosis of breast).

The needle localization wire also identified a fibroadenoma during the lesion removal. Check fibroadenoma in the index, which leads to “Neoplasm, by site benign.” The neoplasm table (under “breast, benign”) directs you to code 217 (benign neoplasm of the breast).

The physician also identified several skin tags as papillomas. Check under the main term papilloma; which states “See Neoplasm by site benign.” For skin tags, you also would check the term skin in the neoplasm table and the term axilla under skin where you are directed to use code 216.5.

CPT Procedure Codes

19125LT Excision of breast lesion identified by preoperative placement of radiological marker; single lesion

19290LT Preoperative placement of needle localization wire, breast

19120LT Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion, open, male or female, one or more lesions

11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

Check the main term “Breast, excision, lesion by needle localization,” and you will see the 19125-19126 code range. After verifying the code description, you will see that 19125 is assigned for the excision of a breast lesion identified by preoperative radiological marker; single lesion. Assign the modifier LT (left side of body) to code 19125.

Because a preoperative radiological marker (needle localization wire) was used to identify this lesion, you also need to assign the code for its placement. See the term “Breast, Needle Wire Placement” in the index. Check the description for code 19290, and you will see that it describes the placement of the needle localization wire. (In some facilities, this procedure code may be assigned by the chargemaster.) Assign modifier LT to code 19290.

During the procedure, a second lesion was identified and removed but not identified by a needle localization wire. Again, check the term “Breast, Excision, lesion,” and you will see the same code range as above. Check the descriptor for code 19120, which identifies the excision of the lesion. Assign the modifier LT to this code.

To report skin tags’ removal, check the main term Removal, and note the secondary index term of Skin tags — 11200-11201. The code descriptor for 11200 indicates the “removal of skin tags, multiple up to 15 lesions.” This is the correct code to assign as a total of four skin tags were identified and removed.

Peggy Hapner is the manager of the health information management consulting division at Medical Learning Inc. (MedLearn®), St. Paul, MN.

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