General Surgery Coding Alert

Question: Two weeks following a left-breast, wire-localized lumpectomy, our surgeon performed a left-breast margin re-excision of anterior, posterior, and lateral margins, as well as a right-breast wire localized lumpectomy. The findings were left breast invasive lobular carcinoma in anterior and lateral margins, and right breast complex sclerosing lesion.

Should I use codes 19301-58 as well as 19125-59, and should I use LT and RT modifiers to distinguish the procedures?

Nebraska Subscriber

Answer: Based on the information you’ve provided, the best coding appears to be 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) with modifiers 50 (Bilateral procedure) and 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). 

Unless the surgeon removed tissue without attention to surgical margins, you should not report 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion). Because the surgeon performed a lumpectomy and identified specific margins in the re-excision, code 19125 isn’t appropriate for the left or right breast. 

Modifiers: You don’t need to use left and right modifiers LT and RT. Instead, modifier 50 for bilateral procedure indicates that the surgeon performs the lumpectomy on both breasts.

Because the number of global days for 19130 is 90 days and the surgeon returns for the re-excision within that time frame, you should additionally report modifier 58.