tci General Surgery Coding Alert - 2011 Issue 1

Reader Questions: 19125, 19301 Distinction Needs Margin Documentation

Question:We had a patient with a breast cancer diagnosis, and the surgeon identified the procedure as "wide local excision" with needle localization. However, the body of the operative note fails to mention anything about the margins except "wide local excision site was well irrigated." Can we report this as 19301, or must we resort to 19125 for lack of margin documentation?Ohio SubscriberAnswer: The documentation you describe supports reporting 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion).You are correct to focus on the margins as a key distinction between 19125 and...

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