General Surgery Coding Alert

Append 58 for additional procedures during global period Surgeons will sometimes return a patient to the operating room to remove additional breast tissue following excision to eliminate all malignancy. When this occurs, you-ll want to scan the operative note for evidence that the surgeon performed a partial mastectomy rather than a less-comprehensive excision.
Margins Define Partial Mastectomy If the surgeon removes a lesion plus a significant portion of surrounding tissue, you may report a partial mastectomy (19301, Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]). If the surgeon removes the lesion and only a small portion of surrounding tissue, the excision code (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, one or more lesions) is more appropriate. Just -adequate- will do: Neither CPT nor CMS requires that the margins be of a specific size (for instance, 1 cm or more) to define a partial mastectomy. Rather, in the surgeon's best clinical judgment, the margins must be -adequate- to remove all possible malignant tissue surrounding the excised mass.
Bonus: By properly identifying a partial mastectomy (19301) over an excision (19120), you capture slightly more RVUs (6.01 vs. 5.84), and improve payment. Ask surgeons for specific documentation: Educate your surgeons about what you need to see in the operative note to assign a partial mastectomy code. Although measurements are valuable, even better is a statement noting, -Allowed minimum margins sufficient to remove all suspected malignancy,- or similar language. What to avoid: You shouldn't base your code choice on terms such as -lumpectomy,- -tylectomy- or -segmentectomy- in the surgeon's documentation. These descriptions are so widely applied that -- depending on how much tissue the surgeon removed -- either 19120 or 19160 could apply.
Watch Re-Excisions Even Closer If the surgeon removes additional tissue during the post-op period of initial breast excision, you should consider the claim with even greater scrutiny. In such a case, the re-excision will more likely qualify as a partial mastectomy. -I believe in this situation the surgeon is returning the patient to the OR to obtain adequate margins. Therefore, 19301 would be more appropriate than an excision code,- says coder Mindy Galbraith at Kootenai Surgery, a prac-tice with five general surgeons in Coeur d-Alene, Idaho. Note: General Surgery Coding Alert (Vol. 9, No. 8) featured a Reader Question (-Global Re-Excision Needs 58- on page 58) that stated you should apply an excision code for removal of additional tissue following breast excision. Although such a re-excision might call for 19120, for instance, the procedure would perhaps more easily qualify as a partial mastectomy (19301), depending on the nature of the margins as reflected in [...]