louise Posted Wed 17th of July, 2019 08:54:13 AM
EXCISIONAL BIOPSY with GW localization : two masses, one was located superiorly at the 12:00 position and the second was inferior at the 2:00 . A radial incision was made between these two masses. Subcutaneous tissues were dissected using electrocautery. We first directed our attention to the superior mass. We traced the wire to localize the mass. Electrocautery was used to dissect through an adequate rim of healthy tissue on all four sides of the mass and then beneath. We then turned our attention to the inferior mass. We traced the wire to localize the mass. Electrocautery was used to dissect through an adequate rim of healthy tissue .
SuperCoder Answered Thu 18th of July, 2019 09:45:04 AM
Thank you for your question.
As per the above suggested codes, CPT® code 19125 seems most appropriate.
In this procedure, the provider accesses the aberrant tissue or lesion through an open incision over the breast at the site indicated by the marker. She carries the incision down to the depth of the marker. She excises the lesion and its surrounding tissue and cauterizes the vessels to prevent bleeding.
Radiological marker placement is one method in which a needle/wire is inserted with the help of radiological guidance (e.g. ultrasound, mammography, MRI, stereotactic imaging) and put into position at the exact location of the tumor.
Note: Since, two masses were dissected, one superiorly and another mass inferiorly. Report an additional CPT® code +19126 along with 19125.
In CPT® code 19120, the provider excises aberrant breast tissue such as a cyst, tumor, or fibroadenoma. She makes an incision on the skin above the lesion to access the abnormal tissue. There is no utilization of any radiological marker, i.e. wire/needle to indicate the site.
In CPT® code 19301, the partial mastectomy is performed to eradicate cancerous (or suspected to be cancerous) lesions or a lump in the breast through an open and incisional process. A physician makes an incision with a scalpel over the lump and the suspected lump is excised along the margin.
There is no utilization of any radiological marker, i.e. wire/needle to indicate the site.
Hope that helps!