General Surgery Coding Alert

'Lumpectomy' is a general term, so proceed with caution when choosing excision/mastectomy codes During breast procedures, if the surgeon removes a lesion along with a significant portion of surrounding tissue, you should choose a partial mastectomy code. If the surgeon removes only the lesion and a small portion of surrounding tissue, an excision code is probably more appropriate.
 
Here are four rules that can help guide you through the decision process: Rule 1: Consider Intent to Obtain Margins As a general guideline, if the surgeon 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 surgeon 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 surgeon removes possible malignant tissue surrounding the excised mass.

"Despite a surgeon'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 of surgery at the University of Pittsburgh School of Medicine and attending breast surgeon for the Magee-UPCI Breast Program.

Documentation matters: "This is the case where you are going to have to have some physician education," says Kim Garner, CPC, CCS-P, CHCC. "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. Minimal Margins Call for 19120 If the surgeon 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 surgeon 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.

Watch for "staged" procedures: If the surgeon removes only the lesion with minimal margins (19120), but the pathology report reveals malignancy, the surgeon must return the patient to the operating room and remove additional tissue, says South Carolina general surgeon M. Trayser Dunaway, MD. In such a case, you may report the follow-up procedure using the partial mastectomy code (19160) with modifier 58 (Staged or related procedure or [...]