CODING CORNER: Conquer Breast Procedure Coding With Margin Facts

Don't make these dangerous assumptions about 'lumpectomy' documentation

Lumpectomies, partial mastectomies, and quandrantectomies can all look alike in the physician's documentation. Check the measurements closely and stay on top of the physician's language to make sure you choose the correct breast procedure code.
 
Collaborate With Physicians for Margins
As a general guideline, if the physician removes a breast lesion along with a margin of healthy tissue, you can choose the partial mastectomy code (19160, Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) to describe the procedure. In this case, the doctor usually assumes that the mass is malignant.
Don't get hung up on measurements: There is no specific requirement in CPT or CMS regulations that says the margin must be of a specific size (for instance, 1 cm or more) to qualify as a partial mastectomy. Rather, the margins must only be "adequate" to ensure that the physician removes possible malignant tissue surrounding the excised mass.
"Despite a physician's best effort to clear a lesion with margins, he may not get 1 cm but still could have performed a segmental mastectomy," says Donald Keenan, MD, PhD, assistant professor at the University of Pittsburgh School of Medicine.
Documentation matters: "This is the case where you are going to have to have some physician education," says Kim Garner, CPC, CCS-P, CHCC, an independent coding and reimbursement consultant in Auburn, Ala. "The doctors are going to have to start putting in their operative report that they paid special attention to the surgical margins." Without documentation of margin removal, you cannot claim 19160.
Report 19120 for Little Margins
If the physician removes only the tumor and no or very little margin, the excision code (19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], open, male or female, one or more lesions) is most appropriate. In such a case, the lump is likely fairly small and clearly defined, and the doctor assumes the tumor is not malignant.
"If I have histological confirmation that a lesion is benign, then I excise the lesion, taking minimal, if any, surrounding breast tissue," Keenan says.
 
Remember: Because the results of the first excision led to the decision to perform the partial mastectomy, you should report both procedures separately when the documentation supports it, according to CMS guidelines outlined in the National Correct Coding Initiative and elsewhere.
Recheck Division for 19160
The term "quadrantectomy" in 19160's definition means that you can safely choose 19160 instead of 19120 if the doctor removes at least a quarter of the breast tissue, Garner says.
Note, however, that CPT does not explicitly define when a [...]

- Published on 2005-08-12