General Surgery Coding Alert

Question: I’m coding an op report and the surgeon describes the breast procedure as “wide excision.” The report mentions margin excision, but not lymph nodes. Could you help me decipher if this is a biopsy or mastectomy or something else, and what code I might use for the procedure?

Nebraska Subscriber

Answer: Without reading the entire op note, it appears that the procedure is 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)).

Clues: The fact that the report mentions margin excision points to the mastectomy codes rather than breast biopsy codes. A biopsy involves sampling a suspicious lesion without trying to remove it entirely, so that type of procedure does not involve margin evaluation.

The second important clue is the fact that this is an “excision,” not the removal of the entire breast. That means you’re not dealing with a complete mastectomy code.

The final clue is that the note doesn’t mention lymph nodes. For a similar excision that also involved axillary lymph nodes, you would instead report 19302 (… with axillary lymphadenectomy).

Glossary: When you’re coding breast cases, it’s helpful to know that the procedure you’ve described might be called by many names, such as lumpectomy, breast-conserving surgery, partial mastectomy, tylectomy, quadrantectomy, segmentectomy, and wide excision.