General Surgery Coding Alert

Question: Our surgeon performs a breast biopsy. The pathology report comes back malignant, and the surgeon performs a simple mastectomy. Is the mastectomy related or unplanned? What modifier should I use?

Texas Subscriber

Answer: The mastectomy is a related procedure to the initial breast biopsy, so you should use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

Do this: Report the biopsy using the code that best describes the surgeon's method, such as 19101 (Biopsy of breast; open, incisional). You should also report the mastectomy as 19303 (Mastectomy, simple complete). Assuming that the mastectomy was within the 10-day global period for the biopsy, you should append modifier 58 to 19303.

Don't forget: If the surgeon performs the mastectomy and biopsy at the same surgical session, you can separately report the biopsy only if the surgeon documents that the decision to perform the mastectomy was based on the biopsy results. If you have proper documentation, code the biopsy separately using modifier 59 (Distinct procedural service).