AHA Coding Clinic® for HCPCS - 2021 Quarter 3; Ask the Editor
Excision of benign breast mass
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. ...
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Article Overview
This article addresses coding questions for excision of benign breast masses using an operative example involving bilateral breast lesions, specimen handling, and tissue rearrangement for closure. It is aimed at coders, billers, and revenue cycle staff who need to interpret breast surgery documentation and distinguish among related CPT options based on the reported procedure context. The discussion focuses on the surgical service, associated operative details, and how the article frames the coding issue.
Why This Topic Matters
Breast mass excision reports can include overlapping surgical concepts such as biopsy-style excision, margin assessment, and closure techniques. Understanding the article’s scope helps coding staff identify the relevant CPT discussion and evaluate documentation for proper procedure reporting.
What You Will Learn
- How the article frames a coding question involving excision of benign breast masses.
- Which operative documentation elements are highlighted as relevant to CPT selection.
- How the discussion distinguishes breast mass excision from other breast surgery contexts.
Who Should Read This
- Medical coders
- Billing specialists
- Revenue cycle staff
- Surgery coders
Codes Discussed
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