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.

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.

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 the surgeon's documentation.

If the surgeon returns the patient to the operating room during the global period of the initial excision, be sure to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 19301 or, less likely, 19120, as appropriate.

-Appendix A of CPT gives three cases in which you might apply modifier 58,- said Kim Garner, CPC,

CCS-P, CHCC, an independent coding and reimbursement consultant, providing audit, training and oversight of coding and reimbursement functions, during a 2006 Coding Institute teleconference, -Nine Proven Solutions Guarantee Breast Surgery Pay-Up.- These situations include if the follow-up procedure was:

• planned prospectively at the time of the original procedure (staged)
• for therapy following a diagnostic surgical procedure more extensive than the original procedure.

For follow-up excision or mastectomy to obtain a wider margin, removal of additional breast tissue is clearly -more extensive- than the original excision, Garner said.

Often with partial mastectomy, the surgeon will perform an axillary lymphadenectomy. The surgeon may also remove the nodes in the axilla through a separate incision at the same time.

In such cases, you should report 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy) for the combined procedure rather than reporting 19301 and 38745 (Axillary lymphadenectomy; complete) separately.

There is a -staged- exception: Following some partial mastectomies (19301), the surgeon may return during the post-op period to see if there has been any lymph node involvement and, if so, may remove the nodes at that time. In this case, you would report the lympha-denectomy as a staged procedure using 38745-58.