tci General Surgery Coding Alert - 2008 Issue 1

That Re-Excision Could Be a Mastectomy: Here's How to Tell

Append 58 for additional procedures during global period Surgeons will sometimes return a patient to the operating room to remove additional breast tissue following excision to eliminate all malignancy. When this occurs, you-ll want to scan the operative note for evidence that the surgeon performed a partial mastectomy rather than a less-comprehensive excision. Margins Define Partial Mastectomy If the surgeon removes a lesion plus a significant portion of surrounding tissue, you may report a partial mastectomy (19301, Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]). If the surgeon removes the lesion and only a small portion of surrounding tissue...

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