General Surgery Coding Alert

Question: In the operation report I’m currently coding, the surgeon has characterized the breast procedure as a “wide excision.” The document refers to the excision of a margin, but there’s no mention of lymph nodes. I’m trying to determine whether this is a biopsy, mastectomy, or another type of procedure. I would also appreciate guidance on the appropriate code to use for this procedure.

RCI Subscriber

Answer: Going by the portion of the op note you have included, it appears that the procedure is 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)).

Hints: The mention of margin excision in the report suggests that the procedure is more likely a mastectomy as opposed to a breast biopsy. Biopsies usually involve taking a sample from a suspicious lesion without complete removal, so they do not require margin evaluation.

The second important hint is the fact that this is an “excision,” not the removal of the entire breast. That means you’re not dealing with a complete mastectomy code.

The final hint is that the note doesn’t mention any lymph nodes being involved. For a similar excision that also involved axillary lymph nodes, you would instead report 19302 (… with axillary lymphadenectomy).

Glossary: When you’re coding breast cases, it’s helpful to know that the procedure you’ve described might be called by many names, such as lumpectomy, breast-conserving surgery, partial mastectomy, tylectomy, quadrantectomy, segmentectomy, and wide excision.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC