Vol. 16 •Issue 20 • Page 10
Coding Integumentary System Procedures
Preoperative Diagnosis: Left breast mass; skin tag, left axilla.
Postoperative Diagnosis: Fibrocystic changes of the left breast with fibroadenoma and focal sclerosing adenosis; squamous papilloma (skin tag).
Procedure Performed: Left breast biopsy; removals of axillary skin tag.
Anesthesia: Attended local.
Indications for Procedure: A left breast mass was found during mammography of this 41-year-old woman. Ultrasound confirmed a solid area at 11 o’clock position. No previous biopsies or masses. No family history of breast carcinoma. Options, risks and rationale were discussed, and patient consented to biopsy and X-ray localization.
Operative Findings: Some fibrocystic, perhaps fibroadenomatous, changes and also lipomatous changes. A fairly sizeable lobule of tissue around the area in question was excised. Also a separate nodule was noted after removal of the initial specimen was excised, and this appeared possibly to be a fibroadenoma—but a bit to the lateral aspect of the previous biopsy site in the upper part of the breast.
She also had one large skin tag and a few smaller ones in the axilla, and she wanted to have these removed as well. This was performed with local Xylocaine anesthesia, and the lesions were then clipped off and cauterized.
Operative Technique: After having prepped and draped the area in the usual fashion, 1% Xylocaine with epinephrine was infiltrated into the area. A curved incision was made central to the site of the wire placement. The wire was brought out into the wound, and a lobule of breast tissue was grasped along with the wire. All of the tissue a bit beyond the end of the wire was excised including an area superficial to the wire where it looked like the lesion perhaps was located. This was removed, and hemostasis was accomplished with electrocautery. There was an additional small nodule that appeared to be perhaps a fibroadenoma projecting into the cavity space after tissue excision. This additional nodule was also 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 wound closure, and the patient tolerated the procedure without complications.
1% Xylocaine was then infiltrated at the site of the larger of the skin tags, which were clipped off, and the base was cauterized. The additional three small tags were also clipped off, the bases were cauterized, and the patient left the operating room in satisfactory condition and was taken to the recovery room.
Addendum: X-ray of the tissue removed showed that the lesion in question does appear to be in the specimen initially removed.
ICD-9-CM Code Assignments
Preoperative Diagnoses: Left breast mass; skin tag, left axilla.
611.72 Lump/mass in breast
701.9 Unspecified hypertrophic and atrophic conditions of skin
Postoperative Diagnosis: Fibrocystic changes of left breast, fibroadenoma of left breast, and squamous papilloma (skin tag).
217 Benign neoplasm of breast
610.2 Fibroadenosis of breast
216.5 Benign neoplasm of skin of trunk, except scrotum
CPT Code Assignments, Rationale
Review the case study above and select the procedures to be coded. First, this patient had a left breast lesion, which was localized by placement of a preoperative marker prior to excision. Check in the CPT manual index under the term Excision, Breast. Indented under the term Breast you will find Lesion — 19120-19126 followed by another indent for Needle Localization — 19125-19126.
A reading of the descriptions will lead you to the correct code for the lesion excised, which is 19125. Assign this code for both the facility and professional components. For the facility component, assign modifier LT to communicate that the excision was performed on the left breast.
A second lesion was removed from the cavity, although, unlike the first, it was not identified with a radiological marker. Return to the index under the term Excision, Breast and then Needle Localization. A reading of the descriptions shows that code 19120 is the correct code choice for both components. Again, assign modifier LT to the facility component to communicate that the excision was performed on the left breast.
For the localization wire placement, look in the CPT manual index under the term Placement, Needle Wire. Indented under Needle Wire is the term Breast—19290-19291. Because only one lesion was localized, the descriptions will clarify that the correct code is 19290. Assigned for the facility component and again assign modifier LT to indicate the left breast placement.
Do not assign code 19290 for the excision because the documentation does not indicate that this physician performed the marker placement. Generally, a radiologist places the needle localization wire.
The patient also had several skin tags clipped and cauterized from the axillary area. Look in the index under Removal followed by Skin Tags — 11200-11201. In the documentation, count the number of tags removed. You should count four tags, so you may assign CPT code 11200 for both the facility and professional components.
For this procedure, no modifier is assigned for the facility component. However, because this was a bilateral procedure, you will assign modifier 51 for the physician component.
Summary of CPT Codes
19125-LT Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion
19120-LT Excision of cyst, fibroadenoma, or other benign or malignant tumor, abberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions
19290-LT Preoperative placement of needle localization wire, breast;
11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion
19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, abberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions
11200-51 Removal of skin tags, multiple fibrocutaneous tags, any area up to and including 15 lesions
Peggy Hapner is manager of the health information management consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.