tci General Surgery Coding Alert - 2010 Issue 5

Reader Question: Related Surgery Takes 58

Question: Our surgeon performs a breast biopsy. The pathology report comes back malignant, and the surgeon performs a simple mastectomy. Is the mastectomy related or unplanned? What modifier should I use?Texas SubscriberAnswer: The mastectomy is a related procedure to the initial breast biopsy, so you should use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).Do this: Report the biopsy using the code that best describes the surgeon's method, such as 19101 (Biopsy of breast; open, incisional). You should also report the mastectomy as 19303 (Mastectomy, simple complete). Assuming that...

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