Wiki Needle localized excisional biopsy

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laura_clffrd@yahoo.com

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Any suggestions for a 71 year old Female had a mammotome biopsy showing atypical ductal hyperplasia of that biopsy. Two needles were placed in the x-ray department, identified surrounding a density and also previous clip in right breast. an incision was made between the 2 needles through to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the needles. Would it be 19125?
 
If the surgeon did not take the whole mass/lesion it would not be 19125.
Please post a scrubbed OP note as the original statement does not have enough information to code.
 
incision was made between the 2 needles. the incision was carried to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the 2 needles. this was then sent to radiology with with confirmation, the clip was removed and the density removed. hemostasis was achieved with bovie electrocoagulation. deep subcutaneous tissue was then reapproximated with a running vicryl suture and the skin was reapproximated with running subcuticular stitch.

any suggestions on learning material would be great as well. I recently started a new position and worked radiology before... so surgery and e/m is a little more challenging. This is also a new client so I think the documentation guidelines needs to be reviewed with them as well. I recently ordered the surgery book from aapc and will order the e/m family practice next paycheck. Any additional ideas would be great!
 
From the statement that "the density was removed" I guess an argument could be made that the entire mass/lesion was removed. I have to admit I would query the physician as to whether or not the whole mass/lesion was removed and ask for a corrected OP note but that's just how I do it.
If the whole thing was removed it would be 19125.
I have the Ingenix General surgery coding companion and I love it! It goes into a more in depth description of procedures so that I can compare them to the OP notes to see if the surgery performed meets the criteria of the code I am looking at :D
 
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