General Surgery Coding Alert

Question: What is the line between codes 19120 and 19160? Does the surgeon have to document removal of a full 25 percent of the breast before I can report 19160?


Michigan Subscriber


Answer: There is no clear percentage of tissue the surgeon must remove to report 19160 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) rather than 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). Instead, you should choose a code based more on the surgeon's intention to collect a sufficient margin to remove the lesion.

If the surgeon removes only the tumor and no or very little margin, the excision code (19120) is most appropriate. In such a case, the lump is likely fairly small and clearly defined, and the surgeon assumes the tumor is not malignant.

The term -quadrantectomy- (which means removal of one-quarter of the breast tissue) in 19160's definition means that you can safely choose 19160 instead of 19120 if the surgeon removes at least a quarter of the breast tissue, but CPT does not prohibit reporting 19160 for removal of 20 percent of the breast tissue, for instance--as long as the surgeon takes adequate margins when removing the breast mass.

Look for follow-up excisions: If the surgeon removes only the lesion with minimal margins (19120), but the pathology report reveals malignancy, the surgeon must return the patient to the operating room and remove additional tissue. In such a case, you may report the follow-up procedure using the partial mastectomy code (19160) appended with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

Because the results of the first excision led to the decision to perform the partial mastectomy, you should report both procedures separately, according to CMS guidelines outlined in the National Correct Coding Initiative and elsewhere.

Learn more: For complete information on breast excision procedures, see -4 Rules to Follow to Make the Best of Breast Procedures- in the August 2005 General Surgery Coding Alert on page 57.