General Surgery Coding Alert

Question: Our surgeon excised breast tissue in a procedure he described as a “lumpectomy,” but the op note and the returned pathology report made no mention of surgical margins. Can we report 19301 for the procedure?

Utah Subscriber

Answer: No, you should not bill 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) for a breast excision that doesn’t involve the documented effort to remove margins for pathological diagnosis.

Because some surgeons use the term “lumpectomy” to describe any excision of breast tissue, you can’t base your code choice solely on that term in op note. Technically, lumpectomy describes excision of a small, intact tumor, whether cancerous, precancerous or fibroid, but must include margins.

You should choose a code based on the surgeon’s documented effort to obtain margins around the excised mass, even if the op note uses conflicting terminology to describe the procedure.

Do this: If the surgeon documents removing only the tumor with no mention of margins, the excision code is most appropriate: 19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions.