tci General Surgery Coding Alert - 2021 Issue Q2

Reader Questions: Decipher Breast Note for ‘Wide Excision’

Question: I’m coding an op report and the surgeon describes the breast procedure as “wide excision.” The report mentions margin excision, but not lymph nodes. Could you help me decipher if this is a biopsy or mastectomy or something else, and what code I might use for the procedure? Nebraska Subscriber Answer: Without reading the entire op note, it appears that the procedure is 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)). Clues: The fact that the report mentions margin excision points to the mastectomy codes rather than breast biopsy codes. A biopsy involves sampling a...

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