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Multiple parts for breast tissue

Tamara Posted Thu 29th of September, 2011 12:03:45 PM

Recently Medicare denied payment on a case we received at our facility. We believe Medicare denied payment because of the # of Level 5 biopsies charged.

They might be questioning specimens “D” through “F” as specimens being evaluated for margins.

Please take a look at all the parts, the charges we submitted and give us your recommendations for the correct CPT Codes.

SPECIMEN CPT CODES USED
A. Sentinel Node #1 (frozen)
88307 – prof
88307 – tech
88331 – froz prof
88331 – froz tech
B. Sentinel Node #2 (frozen) 88307 – prof
88307 – tech
88331 – froz prof
88331 – froz tech
C. Right breast lumpectomy (specimen 6 margins inked)
88307 – prof
88307 – tech
D. Right breast inferior margin (3.0 x 2.5 x 2.0 cm inked red)
88307 – prof
88307 – tech
E. Right breast superior margin (3.2 x 1.0 x 1.0 cm inked yellow)
88307 – prof
88307 – tech
F. Right breast medial margin (3.1 x 2.2 1.8 cm inked orange)
88307 – prof
88307 – tech
G. Right breast lateral margin (3.5 x 3.0 x 2.0 inked green)
88307 – prof
88307 – tech
H. Right breast deep margin (2.0 x 2.0 x 0.5 inked black)
88307 – prof
88307 – tech

SuperCoder Answered Thu 29th of September, 2011 16:09:53 PM

You can't bill for the margins separately. Breast excision of lesion requiring microscopic evaluation of surgical margins can be coded as 88307. We can't code 88307 for excision of breast lesion and breast margin separately for each.
So, codes for 6 margins [as indicated in 'C' for lumpectomy], from "D" to "F" here are included in "C". So, medicare has denied from "D" to "F" for reimbursement.

Tamara Posted Tue 04th of October, 2011 19:49:42 PM

We received each of these specimens from the surgeon. We received the lump and then also sections around the lump. Would that make a difference in coding?

Nikhil Answered Tue 04th of October, 2011 19:52:37 PM

No, the coding rules would not allow us code separately

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