Wiki Partial Masetctomy vs excsion-what is the guide?

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finzy

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I work for a breast surgeon and a few of her cases have been down coded from 19301 to 19120 by the hospital coders, they are using the criteria that her op report does not reflect that she went to a certain dept in the Breast to excise the lesion. She does make certain that the margins are clear, and of course she does a sentinal node biopsy. I am new to coding for this particular specialty and want to make sure that we get this situation rectified as soon as we can, I will also add that she came from a large breast center and has not had this problem with the coders before. It seems to me that if the procedure is to be coded strictly based upon the dept of the excision, then why does it not say that in the CPT? I am really hoping that more seasoned coders can weigh in on this debate and help me to "state our case to the hospital coders" apparently they are using the Ingenix guidelines as a basis for the debate.

thanks in advance!
 
I have always understood the partial mastectomy to apply when tissue beyond what is believed to be the actual neoplasm is purposely taken in the effort to get clear margins. Also when a return for wider margins is needed after initial excision of a mass turns out to have positive margins of CA or DCIS. I don't know what is meant by a particular dept of the breast, but it doesn't sound like an appropriate basis for downcoding your claims.
Connie (CPC,CGSC)
 
Is ther any way you can post a note to review. It could be the way it is documented and with out a note it is hard to say. I worked on the hospital side for awhile and we rarely agreed with the physician codes on the operative codes, it was always based on the way things were stated in the note.
 
unfortunately I am guilty of down coding 19301 to 19120 based off of documentation...So this is what happens.

Some doctors, plastics, oncologist only differentiates 19301 malignant or 19120 benign. They would document the same and assume the coder sees it the same. The facts are that there just needs to be better communication between all parties.

You can also ask the hospital coder about this, what is justifiable documentation for a 19301? Are there any specific words shall be dictated or written for the coder to see it justifiable?

Everyone interprets things differently and lack of updated information can have a not fair outcome.

I would look out for documentation such as
-excision with attention to margins
-excised with normal tissue around the wire
-extra tissue circumferentially were obtained

Hope that helps....team work is what it comes down to.

MS
 
thanks so much for all of your helpful feedback, I actually talked to previous coder who worked with my doc in another state, and she told me that in all of the years of working with her , she had been subject to routine outside audits by a company and that not one of her cases was ever flagged by the auditor for being over coded, I also went a ste further and called the company that audited her and I requested a copy of the audit results, and she does dictate with the appropriate comments and attention to clear margins, they are still stuck on the whole idea that if the breast is not excised to a certain depth then it is not meeting criteria. I do feel better about going into this meeting now, and hopefully we will all learn from one another, I truly think that because my doc is such a gifted surgeon and is able to take only "what she absolutely has to", it is kind of confusing to them, apparently the other docs who do breast are a bit more enthusiastic when the excise for clear margins. I will let you all know how I fare this afternoon,

Many many thanks!
 
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