# Needle localized excisional biopsy



## laura_clffrd@yahoo.com (Dec 12, 2011)

Any suggestions for  a 71 year old Female had a mammotome biopsy showing atypical ductal hyperplasia of that biopsy.  Two needles were placed in the x-ray department, identified surrounding a density and also previous clip in right breast.  an incision was made between the 2 needles through to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the needles.  Would it be 19125?


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## Lujanwj (Dec 12, 2011)

Yep, 19125.


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## Grintwig (Dec 12, 2011)

If the surgeon did not take the *whole* mass/lesion it would *not *be 19125.
Please post a scrubbed OP note as the original statement does not have enough information to code.


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## laura_clffrd@yahoo.com (Dec 12, 2011)

incision was made between the 2 needles.  the incision was carried to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the 2 needles.  this was then sent to radiology with with confirmation, the clip was removed and the density removed.  hemostasis was achieved with bovie electrocoagulation.  deep subcutaneous tissue was then reapproximated with a running vicryl suture and the skin was reapproximated with running subcuticular stitch. 

any suggestions on learning material would be great as well.  I recently started a new position and worked radiology before... so surgery and e/m is a little more challenging.  This is also a new client so I think the documentation guidelines needs to be reviewed with them as well.  I recently ordered the surgery book from aapc and will order the e/m family practice next paycheck.  Any additional ideas would be great!


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## Grintwig (Dec 12, 2011)

From the statement that "the density was removed" I guess an argument could be made that the entire mass/lesion was removed. I have to admit I would query the physician as to whether or not the whole mass/lesion was removed and ask for a corrected OP note but that's just how I do it.
If the whole thing was removed it would be 19125.
I have the Ingenix General surgery coding companion and I love it! It goes into a more in depth description of procedures so that I can compare them to the OP notes to see if the surgery performed meets the criteria of the code I am looking at


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## laura_clffrd@yahoo.com (Dec 12, 2011)

Thanks guys!


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