General Surgery Coding Alert

Question:  For a patient diagnosed with breast cancer, the surgeon identified the procedure as “wide local excision” of tumor identified by radiological marker placed preoperatively. The operative note states, “special attention was paid to ensure adequate margins.” Is this a breast lesion excision or lumpectomy?

Michigan Subscriber

Answer:  The best code choice for the procedure you describe is 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]).

Although the surgeon describes the procedure as a lesion excision, two pieces of information identify this as a lumpectomy:

1. The surgeon describes “wide local excision,” which indicates the attempt to have clear margins
2. The op note states, “special attention was paid to ensure adequate margins,” again indicating attention to margins.

If the op note did not focus on the surgeon’s attempt to accomplish clean margins, you would need to report the service as 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion). 

CPT® instruction for the breast excision codes states, “The open excision of breast lesions ..., without specific attention to adequate surgical margins ... is reported using codes 19110-19126.” In contrast, the instructions note that, “documentation for partial mastectomy procedures [19301, 19302] includes attention to the removal of adequate surgical margins surrounding the breast mass or lesion.”

Best documentation: If the surgeon performs a partial mastectomy, the op note should ideally identify the procedure as such, or use another specific procedure descriptor such as lumpectomy, tylectomy, etc. Even though that’s not the case in your example, the surgeon did adequately document the attempt to excise clear margins, which alone justifies the use of the partial mastectomy code.

Radiological marker: Documentation of a pre-surgical radiological marker placement doesn’t preclude selecting 19301 if the surgeon focuses on clear margins. 

Pay difference: The 2014 Medicare Physician Fee Schedule pays for 19125 at a rate of $550.95, and 19301 at a rate of $661.29 (national non-facility amount, conversion factor 35.8228).