General Surgery Coding Alert

Question: A patient presents with a palpable breast density, and the surgeon performs an excisional breast biopsy. When the pathology report returns, the post-operative diagnosis is a silicone granuloma from a previously ruptured silicone gel implant. The revision and replacement of the ruptured implant were performed a year ago. Is the correct procedure code for the biopsy 19330 or 19120?

Washington Subscriber

Answer: The correct code is 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), says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. Although the pathology report describes a silicone granuloma, the goal of the procedure was not to remove an implant but to remove an unknown lump, which subsequently was identified as the granuloma (i.e., silicone surrounded by tissue).

Neither 19330 (removal of mammary implant material) nor 19328 (removal of intact mammary implant) applies in this case because the implant was previously removed. Both 19330 and 19328 would be appropriately used to describe the original removal of the silicone implant.