A patient with discomfort from bilateral breast masses presented for removal via excisional breast biopsies. The lesion in the right breast was identified with the use of ultrasound and an incision was made in a curvilinear fashion. The area of concern was widely excised along with normal breast tissue in an attempt to achieve clear margins. The specimen was sent to pathology for examination. In order to close the large defect created by the excision of the lesion, advancement flaps were utilized by creating rotational pedicle flaps with the surrounding breast tissue to fill the defect. The same procedure was repeated on the left breast.
What is the correct CPT code for excision of a benign breast mass? CPT code 19120 does not include the attention to margins that are detailed in the operative note and CPT code 19301 is reported for treatment or prevention of breast cancer.
Assign CPT code 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, with modifier 50, Bilateral Procedure, for the excision of the bilateral benign breast masses. In addition, it is appropriate to assign an additional code for the advancement flaps.
Although the current CPT guidelines include CPT code 19120 in the list of codes that describe open excision of breast lesion procedures WITHOUT specific attention to adequate surgical margins, the fact that margins were taken in this case does not exclude assigning CPT code 19120 for the excision of the benign lesions.