General Surgery Coding Alert

Question: Which code is appropriate for lump-ectomy? I've heard conflicting advice regarding 19120 versus 19160.

Ohio Subscriber

Answer: There's no easy answer here. Because the term "lumpectomy" is applied so widely, either 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) or 19160 (Mastectomy, partial) may be appropriate, depending on circumstances.

CPT does not assign a "percentage" of tissue that the surgeon must remove to report 19160 instead of 19120, and therefore provides no guideline for when a simple excision "crosses the line" to become a partial mastectomy. The amount of tissue removed during either procedure can vary significantly, but coders will often rely on percentages to select between the codes.

If the surgeon removes only the tumor and a small portion of surrounding tissue with no further margin, the excision code (19120) is more appropriate. In this case, the surgeon assumes the tumor is not malignant with the understanding that if the pathology report reveals a malignant tumor, he or she will have to remove more material at a later date. Physicians perform such excisions when the lump is fairly small and clearly defined so the surgeon feels confident that he or she has removed the entire tumor. Surgeons may also perform sentinel node biopsies when they perform lumpectomy (19120) for malignancies to be sure that metastasis is not a problem.

If the surgeon suspects malignancy, however, and removes the tumor along with a significant portion of surrounding tissue (at least a 1-cm margin of healthy tissue) for local treatment and control, the mastectomy code (19160) is more appropriate. Generally, this would include removal of at least 25 percent of the breast tissue (that is, a quadrectomy). In this case, the surgeon would not expect to have to remove more tissue even if the pathology report does indeed reveal malignancy.