tci General Surgery Coding Alert - 2010 Issue 16

You Be the Coder : Tread Carefully on Gynecomastia Diagnosis

Question: Our surgeon performed an excisional biopsy for a male patient with a painful right breast mass. The pathology report returned with a diagnosis of gynecomastia. What are the correct diagnosis and procedure codes for this case? Oregon Subscriber Answer: Assuming that the surgeon excised the mass, the correct procedure code is 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). The term "excisional biopsy" can be misleading, because the surgeon either excised the mass or incised...

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