Mastectomy vs. Breast Excision: Margins Matter

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  • February 25, 2016
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Mastectomy vs. Breast Excision: Margins Matter

When deciding between 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions and 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy, search the documentation to determine whether a margin of health tissue was removed, along with the breast mass.
If the surgeon removes only the mass, with little or no margin, look first to 19120. Report one unit of 19120, per incision (not per mass removed). CPT® Assistant (March 2005) instructs:

…code 19120 should be reported for each of the separate excised areas since it includes one or more lesions through the same incision. However, if excisions are performed on different areas of the breast through separate incision sites, code 19120 should be reported for each incised area. Modifier 59 [Distinct Procedural Service] should be appended to the second procedure code.

You may report 19120 for breast excision performed on either male or female patients. Note, however, “19120 does not include more extensive resections of breast tissue. More extensive resection performed for gynecomastia [benign enlargement of breast tissue] should be reported with code 19300 [Mastectomy for gynecomastia]” (CPT® Assistant, March 2014). You should claim 19300 only for male patients, “as gynecomastia is a male condition” (CPT® Assistant, Feb. 2007).
When the surgeon removes a breast lesion with a margin of healthy tissue, look instead to 19301. CPT Assistant (Feb. 2007) instructs:
Partial mastectomy procedures describe open excisions of breast tissue and include specific attention to adequate surgical margins surrounding the breast mass or lesion. In a partial mastectomy, a larger amount of breast tissue and some skin are removed with the tumor. This also includes removal of the lining over chest muscles below the tumor. This surgery is usually performed for stage 1 and 2 tumors. This code is reported also for the performance of a lumpectomy where the tumor and a small amount of surrounding tissue are removed.
In these cases, the mass is suspected or known to be malignant, and the margin of health tissue is removed to ensure that the entire malignancy has been excised.
Sometimes, the surgeon may excise a breast mass (19120), but pathology reveals malignancy and the surgeon must return the patient to the operating room and remove additional tissue. When this occurs, CMS rules (National Correct Coding Initiative Policy Manual for Medicare Services, Chapter III, Section J.1) allow you to report the follow-up excision using the partial mastectomy code, 19301, with modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period appended.

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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