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Ob-Gyn Coding Alert

Examine These Breast Excision Factors:

Radiological Marker and Surgical Margins

Published on Tue May 03, 2005

Find out which modifier to use when your ob-gyn removes lesions from both breasts

When your ob-gyn excises a breast cyst or lesion, you need to know two important pieces of information before you even think about choosing a code: whether or not the ob-gyn preoperatively placed a radiologic marker, and whether or not the ob-gyn removed adequate surgical margins in addition to the lesion.

Markers May Mean Reporting Radiological S&I

On the off chance your ob-gyn - instead of a radiologist - documents placing the marker during a lesion excision, you should code for that placement using 19290 (Preoperative placement of needle localization wire, breast) and +19291 (... each additional lesion [list separately in addition to code for primary procedure]) as well as the radiology code that represents the guidance used to place the marker.

Among your options of codes to report with the marker placement are stereotactic localization (76095, Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation), mammographic guidance (76096, Mammographic guidance for needle placement, breast [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation) and ultrasound guidance (76942, Ultrasound guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). This means if the ob-gyn placed the marker and did the guidance, you would use one of these codes for the guidance portion of the service, depending on what your ob-gyn documented.
 
If the ob-gyn placed the marker and removed the lesion, you would code and bill for both procedures and the guidance used for the marker placement (a total of three codes), says Sangeeta Parekh, CPC, practice plan administrator for the USC Department of Surgery, Division of Tumor and Endocrine Surgery, in Los Angeles.

Learn 3 Lesion Codes

You've got three coding options when reporting excision of a breast lesion while leaving the surrounding tissue intact:
 

  • 19120 - Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (expect 19140), open, male or female, one or more lesions
  • 19125 - Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion
     
  • +19126 - ... each additional lesion separately identified by a preoperative radiological marker (list separately in addition to code for primary procedure).

    If the ob-gyn performs an excision of adequate surgical margins, however, you should bump up your code to the level of a partial mastectomy, according to the CPT guidelines.

    Keep in mind: When the ob-gyn identifies the breast lesion preoperatively by the placement of a radiological marker, you should report 19125 instead, Parekh says. You'll use this code for the first lesion. For any additional lesion, you should report 19126, without differentiation of the breast.

    Red flag: You cannot separately report biopsies if the ob-gyn is also excising a lesion, says Patricia Larabee, CPC, CCP, a coding specialist at InterMed in Portland, Maine.

    Mull Over These Modifier Options

    You won't have the option of reporting multiple lesions in the same breast separately when billing 19120, because CPT specifies excision of one or more.

    Therefore, you wouldn't report multiple lesions removed from a single breast, Larabee says.
     
    But you may still be able to report this code with modifiers. If the ob-gyn has to make more than one incision, depending on the area of the breast, you have two options: appending modifier -22 (Unusual procedural services) to 19120, or reporting 19120 two times with modifier -59 (Distinct procedural service) appended to the second code, Larabee says. "I would personally choose the first option."

    Heads-up: CPT specifies that if the ob-gyn removes lesions from both breasts, you should append modifier -50 (Bilateral procedure) to the code, such as 19120-50.

    Example: A 57-year-old woman has breast lesions that the ob-gyn must remove from both the right and left breasts. The radiologist placed three preoperative markers the day before surgery. The ob-gyn removes a lesion on the right breast and two lesions on the left breast, but leaves intact the surrounding tissue.
     
    To correctly code the ob-gyn's services, you should report codes 19125, 19126, and 19126 again on another line. You don't need to append any modifiers in this scenario, because 19126 is a CPT add-on code. The payer should not reduce your fee for this second code (that is, they should pay 100 percent of their allowable) because its value has already been reduced by the RVU assigned to the code.

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