Inpatient Facility Coding & Compliance Alert

Question: While performing the breast lumpectomy operation the provider decides to remove more tissue based on pathology findings and he goes on to perform a simple mastectomy. Is it possible to bill both procedures, or do we have to bundle the lumpectomy with the mastectomy?

Illinois Subscriber

Answer: With appropriate documentation and modifiers, you can separately bill the lumpectomy (19301, Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) and the mastectomy (19303, Mastectomy, simple, complete) in this case.

Because the decision for the mastectomy was based on the lumpectomy findings during surgery, you should code the two procedures separately. 

Here’s what CMS says about it in the Correct Coding Initiative (CCI) Policy Manual: “If the breast excision procedure precedes the mastectomy for the purpose of obtaining tissue for pathologic examination which determines the need for the mastectomy, the breast excision and mastectomy codes are separately reportable.”

CCI bundles 19301 as a component of 19303, so you’ll need to override the edit pair when you have documentation that unbundling is appropriate, as in this case. 

Plus: You need to append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to 19301, which is the column 2 code, to show that this was a staged procedure.