tci General Surgery Coding Alert - 2014 Issue 7

Reader Question: Consider Global and Bilateral for Code Selection

Question: Two weeks following a left-breast, wire-localized lumpectomy, our surgeon performed a left-breast margin re-excision of anterior, posterior, and lateral margins, as well as a right-breast wire localized lumpectomy. The findings were left breast invasive lobular carcinoma in anterior and lateral margins, and right breast complex sclerosing lesion. Should I use codes 19301-58 as well as 19125-59, and should I use LT and RT modifiers to distinguish the procedures? Nebraska Subscriber Answer: Based on the information you’ve provided, the best coding appears to be 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]) with modifiers 50 (Bilateral procedure)...

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