surgerycoder
Contributor
I have read through different threads (from a few years back) and am still a little confused.
Patient had bilateral lumpectomies (with attempt to obtain clear margins-per previous OP report) two weeks prior.
Patient found to have residual DCIS by pathology and returned to OR to lift muscle sparing latissimus flap and re-excise margin of the breast lumpectomy.
New OP report
Procedure: Re-excision of medial inferior margin
.....We opened up her previous incision and rotated her latissimus flap laterally. We identified the medial inferior aspect of her lumpectomy cavity and excised these margins together. This specimen was oriented and sent to pathology for evaluation. We obtained hemostasis and used clip to re-mark the medial margin of her lumpectomy cavity........
Would the correct CPT for the re-exision be 19120-58 or 19301-58?
From what I have read it, it could go either way, depending on the surgeons documentation. Since this operative report doesn't state.....excised the medial inferior margin and additional margin in attempt to obtain further clear margins, and just states that the margin was identified and excised together, then I would think 19120-58, sounds correct for this one. I think I may just reading to much into this one, but wanted to double check.
Thank you,
Patient had bilateral lumpectomies (with attempt to obtain clear margins-per previous OP report) two weeks prior.
Patient found to have residual DCIS by pathology and returned to OR to lift muscle sparing latissimus flap and re-excise margin of the breast lumpectomy.
New OP report
Procedure: Re-excision of medial inferior margin
.....We opened up her previous incision and rotated her latissimus flap laterally. We identified the medial inferior aspect of her lumpectomy cavity and excised these margins together. This specimen was oriented and sent to pathology for evaluation. We obtained hemostasis and used clip to re-mark the medial margin of her lumpectomy cavity........
Would the correct CPT for the re-exision be 19120-58 or 19301-58?
From what I have read it, it could go either way, depending on the surgeons documentation. Since this operative report doesn't state.....excised the medial inferior margin and additional margin in attempt to obtain further clear margins, and just states that the margin was identified and excised together, then I would think 19120-58, sounds correct for this one. I think I may just reading to much into this one, but wanted to double check.
Thank you,