CCO Admin asked:
After informed consent was obtained from the patient; the patient was initially taken to radiology for needle localization of the mass. The wire was placed just anterior to the area where the mass was located at. Subsequently she was taken to the operating room. The right breast was prepped and draped in the usual sterile fashion. Using a #15 scalpel blade; a circumareolar incision was made. Incision was then carried through a small amount of subcutaneous tissue with the knife very carefully using the cold knife; the areola as well as the nipple areolar complex were carefully separated from the rest of the breast tissue with the knife. A large dilated duct was identified; which actually contained the mass in question.
The duct was suture ligated from the inside with a 3-0 Vicryl suture. The dissection was then continued all the way around it using electrocautery all the way down to the prepectoral fascia. The mass in question containing the marking wire was then carefully separated from the skin and the rest of the breast tissues and excised. It was sent for radiologic confirmation. The wound was then irrigated. Hemostasis was achieved with the electrocautery. The nipple areolar complex was then reapproximated using interrupted 3-0 subdermal sutures and the skin was closed using subcuticular sutures of 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well; was transferred to the recovery room in stable condition.
I am trying to determine if the code would be 19125 or 19120. Any suggestions? https://www.supercoder.com/coding-newsletters/my-pathology-lab-coding-alert/biopsy-or-excision-difference-explained-in-coding-terms-article
Answer:
19125 because she was taken to radiology first for the needle localization of the mass.
"19120 - Excision of cyst; fibroadenoma; or other benign or malignant tumor; aberrant breast tissue; duct lesion; nipple or areola lesion (except 19140); open; male or female; one or more lesions
19125 - Excision of breast lesion identified by preoperative placement of radiological marker; open; single lesion" https://www.supercoder.com/coding-newsletters/my-pathology-lab-coding-alert/biopsy-or-excision-difference-explained-in-coding-terms-article
After informed consent was obtained from the patient; the patient was initially taken to radiology for needle localization of the mass. The wire was placed just anterior to the area where the mass was located at. Subsequently she was taken to the operating room. The right breast was prepped and draped in the usual sterile fashion. Using a #15 scalpel blade; a circumareolar incision was made. Incision was then carried through a small amount of subcutaneous tissue with the knife very carefully using the cold knife; the areola as well as the nipple areolar complex were carefully separated from the rest of the breast tissue with the knife. A large dilated duct was identified; which actually contained the mass in question.
The duct was suture ligated from the inside with a 3-0 Vicryl suture. The dissection was then continued all the way around it using electrocautery all the way down to the prepectoral fascia. The mass in question containing the marking wire was then carefully separated from the skin and the rest of the breast tissues and excised. It was sent for radiologic confirmation. The wound was then irrigated. Hemostasis was achieved with the electrocautery. The nipple areolar complex was then reapproximated using interrupted 3-0 subdermal sutures and the skin was closed using subcuticular sutures of 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well; was transferred to the recovery room in stable condition.
I am trying to determine if the code would be 19125 or 19120. Any suggestions? https://www.supercoder.com/coding-newsletters/my-pathology-lab-coding-alert/biopsy-or-excision-difference-explained-in-coding-terms-article
Answer:
19125 because she was taken to radiology first for the needle localization of the mass.
"19120 - Excision of cyst; fibroadenoma; or other benign or malignant tumor; aberrant breast tissue; duct lesion; nipple or areola lesion (except 19140); open; male or female; one or more lesions
19125 - Excision of breast lesion identified by preoperative placement of radiological marker; open; single lesion" https://www.supercoder.com/coding-newsletters/my-pathology-lab-coding-alert/biopsy-or-excision-difference-explained-in-coding-terms-article
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