Cheryl Posted Mon 24th of February, 2020 16:28:24 PM
Patient had RF Tag surgical excision of 2 masses in the right breast. Patient during the same surgery had a margin re-excision on the left breast with inclusion of RF tag localized left breast. Previous Lt breast excision 1 month prior showed pathology of Phyllodes tumor, therefore re-excision was recommended. Latest Path report stated: RF Tag re-excision 1.0cm Fibroadenoma, left breast. How should this be coded: Rt breast: 19125 & 19126.... Lt breast: 19125,58 ?
SuperCoder Answered Tue 25th of February, 2020 08:13:57 AM
When the physician identifies the breast lesion preoperatively by the placement of a radiological marker, you should report 19125. You'll use this code for the first lesion. For any additional lesion, you should report 19126, without differentiation of the breast.
As per the provided documentation, the given codes seem to be correct. For more appropriate answer please provide some more details of procedure performed on left breast.
Cheryl Posted Wed 26th of February, 2020 14:23:21 PM
The left breast had a Phyllodes tumor excised on 12/19. During the recent procedure where 2 masses were excised on the right breast, the surgeon also performed a margin re-excision of the RF tag mass on the left breast. The lastest path report on the re-excision of the left breast margin stated 1.0 cm tumor mass and disrupted fibroadenoma. I am not sure how to code the left breast re-excision. Thank you!
SuperCoder Answered Thu 27th of February, 2020 04:27:16 AM
As per the provided documentation, physician had removed tumor mass and fibroadenoma from the left breast. There is specific code for removal of fibroadenoma, or other benign or malignant tumor i.e. 19120. So, if the surgeon had removed tumor and no or very little margin, the excision code 19120-58 would be the better choice (19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions).