tci General Surgery Coding Alert - 2015 Issue 11

Reader Question: Seek Margin Documentation for Lumpectomy

Question: Our surgeon excised breast tissue in a procedure he described as a “lumpectomy,” but the op note and the returned pathology report made no mention of surgical margins. Can we report 19301 for the procedure? Utah Subscriber Answer: No, you should not bill 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) for a breast excision that doesn’t involve the documented effort to remove margins for pathological diagnosis. Because some surgeons use the term “lumpectomy” to describe any excision of breast tissue, you can’t base your code choice solely on that term in...

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