tci General Surgery Coding Alert - 2014 Issue 6

Reader Question: Document Decision for Further Breast Surgery

Question: The surgeon performs a breast lumpectomy and the pathology findings during surgery indicate that the surgeon needs to remove more tissue. The surgeon goes on to perform a simple mastectomy. Can we bill both procedures, or do we have to bundle the lumpectomy with the mastectomy? SuperCoder.com Subscriber Answer: With appropriate documentation and modifiers, you should be able to separately bill the lumpectomy (19301, Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) and the mastectomy (19303, Mastectomy, simple, complete) in this case. Because the decision for the mastectomy was based on the lumpectomy findings during surgery, you...

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