Get a Physician’s Perspective on Breast Health and Coding
An interview between a surgical coder and a breast surgeon uncovers essential clinical and medical coding guidance.
Breast health is an important topic for all women, and should be for men, as well. It’s especially important for Sasa-Grae Espino, MD, breast surgeon at Southside Physicians Network in Petersburg, Va. She is passionate about educating her patients on the necessary steps to maintain health and well-being, as well as educating coders to make sure we understand what her procedures entail.
Code descriptions can sometimes be confusing for a new coder. You are expected to understand what the physician does during a procedure and how to determine if things go above and beyond, without observing a procedure or undergoing the same training as a physician. The following interview with Dr. Espino will help you understand coding through a physician’s eyes, and hopefully bridge the gap between you and your physician.
Cynthia Briggs, CPC, CPMA, CCVTC (CB): As coders, we understand the difference between core needle and incisional biopsies, but can you explain what factors into your decision-making when determining which method to use?
Sasa-Grae Espino, MD (SGE): Core needle biopsies are usually performed when the mass is deeper in the breast, and a longer instrument is needed to reach it such as a core needle instrument. Many times, I use ultrasound to visualize the mass underneath the skin and subcutaneous tissue, target my area, and then insert the needle into the breast several centimeters deep to reach the suspicious mass. An incisional biopsy is exactly what it sounds like: An incision is made on the breast skin itself to take a piece of the breast tissue, as well as the skin and underlying dermis. This is then closed, primarily to ensure the wound heals well.
CB: Can you give us a brief example of what a note might look like for each of these procedures? Any hints of things that coders might look for to properly code each?
SGE: Core needle biopsy: Stab incision made with a scalpel and a core needle biopsy instrument inserted, taking multiple cores of tissue.
Incisional biopsy: Punch biopsy instrument or scalpel used to dissect a small amount of skin, subcutaneous tissue and underlying breast tissue. Hemostasis obtained prior to closure of the wound with a suture or Steri Strips.
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
19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single excision
19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)
According to Briggs and Dr. Espino, the most commonly used breast health codes are:
19100 Biopsy of the breast; percutaneous, needle core, not using imaging guidance (separate procedure)
19101 Biopsy of breast; open, incisional
CB: During coding classes we are taught the main difference between an excision and a lumpectomy is the documentation of margins. Are there any other items we should look for to help us differentiate between the two?
SGE: The biggest thing that differentiates an excision from a lumpectomy for me is the concern for malignancy. If I’m not sure what the final pathology is, then there is no reason to take too much breast tissue and I perform an excisional biopsy by removing a small but adequate amount of breast tissue that can give us better samples to look at. If there’s definitely cancer there, then I use a lumpectomy code, which implies I’ve taken the cancer, as well as a small sliver of healthy tissue around it to achieve negative margins.
CB: What are the clinical indications for each of the mentioned procedures? How do you determine when to place a marker versus when not to?
SGE: I think the only reason to code a lumpectomy is if there’s a known cancer there. I always place markers within the lumpectomy cavity because most lumpectomies need adjuvant radiation, and the clips help the radiation oncologists know where my area of resection was made.
CB: Can you give a brief example of what a note might look like for each of these procedures?
SGE: Lumpectomy: A curvilinear incision was made overlying the mammographic abnormality, carried down through the skin. Electrocautery was used to dissect a cylindrical piece of tissue. Specimen X-ray confirmed we had the abnormality. Additional margins were obtained on all six sides. Excisional biopsy would not necessarily include the X-ray and does not have additional margins.
14000 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
CB: I have noticed you perform an extra step on your excision and lumpectomy patients that not all providers perform. Can you explain why you perform the adjacent tissue transfer and give an example of how it would appear in your operative report?
SGE: Let me start off by saying I hate removing an unnecessary amount of breast tissue. The goal of a breast cancer surgery is to get out the cancer, achieve necessary margins, and to leave the breast looking as symmetrical as the other breast; however, more often than not, removing even the smallest amount of breast tissue can cause a visible, slight defect at the area of resection. I move tissue around the breast to help fill in that defect and make the breast look like I’ve never operated on the patient at all.
Coding example: To minimize the contour changes, an adjacent tissue transfer was performed. This was done by developing the tissue plane between the breast tissue and underlying pectoralis muscle. Once this was completed, the breast tissue was mobilized and approximated using 3-0 PDS sutures. Approximately 15 sq. cm. of tissue was dissected, mobilized, and advanced. This nicely filled the cavity to maintain a normal contour.
19303 Mastectomy, simple, complete
Use modifier 22 Increased procedural service when a nipple sparing, skin sparing procedure is documented.
19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle
+38900 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)
38525 Biopsy or excision of lymph node(s); open, deep axillary node(s)
CB: What is the difference between a simple, complete mastectomy and nipple sparing, skin sparing mastectomy? How does your documentation change?
SGE: We used to be afraid of the word mastectomy because it meant removing the breast and leaving the woman flat, and some women feel it takes away femininity and sense of self. What’s so cool now is that we can perform nipple and skin sparing mastectomies that allow us to remove all the breast tissue and the cancer and all its badness while still leaving the skin envelope intact. This gives us the opportunity to place an implant underneath the skin and make it look like the woman still has her breasts. As for coding, documentation either says that a nipple-sparing inframammary fold incision or a skin-sparing peri-areolar incision was made and subsequent dissection was performed carefully to create viable mastectomy skin flaps. I also send a separate subareolar biopsy for my nipple-sparing mastectomies.
CB: Why do you perform a simple, complete mastectomy with node mapping and lymph node biopsy instead of a modified radical mastectomy (MRM)? Why not just remove all of the lymph nodes?
SGE: Again, I am a surgeon and I love to operate, but only when it’s necessary. I try to minimize the amount of resection I do if possible because more surgery can potentially lead to more downstream complications, such as lymphedema, which permanently limits the lifestyle of patients who get it. And the risk of lymphedema is significantly increased with removing all the lymph nodes. Mastectomy with mapping and lymph node biopsy (and possibly axillary dissection during the same surgery if the biopsy is positive for cancer on frozen section)
is the standard for breast cancer care, unless the patient has a diagnosis of inflammatory breast cancer (IBC). IBC necessitates an MRM.
CB: Lastly, why is breast health so important to you? How often should women get mammograms and why?
SGE: Without a doubt, this is mostly my mom’s doing. She developed breast cancer during my first year of medical school and that stuck with me. Breasts are also so important to me as a woman because they help identify us as women, mothers, and lovers. And it angers me that a cancer should dare to threaten my life with my breasts and compromise that identity. Women should get mammograms every year starting at the age of 40. They don’t prevent cancers, but they definitely help detect cancers much earlier, which means that we get treated faster, live longer, and can enjoy more of life.
Cynthia Briggs CPC, CPMA, CCVTC, is a surgical coder for Southside Physicians Network-Surgery, Petersburg, Va., where she codes general, bariatric, breast, colorectal, vascular, and cardiothoracic surgeries. She has experience in coding and billing, accounts receivable, with an expertise in radiology accounts. Briggs is a member of the Petersburg Association of Coders (PAC) local chapter. She served as the PAC treasurer in 2015 and as chapter president for 2016 and 2017.