General Surgery Coding Alert

Question: Our surgeon performed an excisional biopsy for a male patient with a painful right breast mass. The pathology report returned with a diagnosis ofgynecomastia. What are the correct diagnosis and procedure codes for this case? Oregon Subscriber Answer: Assuming that the surgeon excised the mass, the correct procedure code is 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, 1 or more lesions). The term "excisional biopsy" can be misleading, because the surgeon either excised the mass or incised a biopsy specimen from the mass. If the op note documents an incisional biopsy instead of an excision of the mass, you should report 19101 (Biopsy of breast; open, incisional). The ICD-9 coding for this case is also problematic.Gynecomastia is usually a clinical diagnosis based on the clinician's observation of male breast enlargement,not a [...]