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tlm5506

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Hello everyone.
My physician performed a wire localization right breast biopsy. That is what he dictated for the title of the procedure. However, in the actual op note he mentions nothing of placement of the wire. He made an incision over the end of the wire and removed the abnormality. I am assuming the wire was placed preoperatively, and if that's the case then I am having difficulty with coding this procedure. I chose a 19101, but I am unsure if this is correct. Thanks for the help.
 
In the physician note, is it understood that the lesion was removed during the biopsy?, because in your question, you stated that the doctor removed the abnormality, and if so, that would be an excision of breast mass in which code 19125 including the markers, would be appropiate.
 
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If the wire was placed pre-operatively for localization and the physician excised the breast mass or lesion I would use Cpt 19125.
 
I like 19125 as well because of the "Preoprative placement of radiological Marker".

Remember, almost everything taken from the body will be biopsied so it's the actual "removal of the abnormality" or lesion that is the coded.
 
Agree with the 19125.
He would not be wrong in referring to it as a "wire-localized" biopsy even if he didn't place the wire. Sometimes these are placed by the radiologist before hand. There is a wire there to guide him, and so his terminology is correct.
 
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