General Surgery Coding Alert

Question:We had a patient with a breast cancer diagnosis, and the surgeon identified the procedure as "wide local excision" with needle localization. However, the body of the operative note fails to mention anything about the margins except "wide local excision site was well irrigated." Can we report this as 19301, or must we resort to 19125 for lack of margin documentation?Ohio SubscriberAnswer: The documentation you describe supports reporting 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion).You are correct to focus on the margins as a key distinction between 19125 and 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]). CPT instruction for the breast excision codes states, "the open excision of breast lesions ..., without specific attention to adequate surgical margins ... is reported using codes 19110-19126." In contrast, the instructions note that, "documentation for partial mastectomy procedures [19301, 19302] includes attention to the [...]