General Surgery Coding Alert

Question: The patient underwent a partial mastectomy of the left breast nearly two months ago. Because of positive margins on the pathology report, the surgeon decided to re-excise to remove additional tissue. How should we report the re-excision?


Texas Subscriber

Answer: Assuming that the surgeon intended to ensure adequate margins during the first excision, you should have reported that procedure using 19160 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]). Because you state -partial mastectomy,- we can assume this was the case.

But if the surgeon had removed only the tumor and no or very little margin, the excision code would be the better choice (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).

In either case, report the follow-up -re-excision- during the global period using 19160 appended with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period). Using the modifier lets the payer know that the re-excision during the global period is related to but more extensive than the initial excision.

You could also add modifier LT (Left side) to 19160-58 to indicate the precise location of the excision (in other words, the left breast).

In this case, you will most likely choose a diagnosis of 174.9 (Malignant neoplasm of female breast, unspecified).