General Surgery Coding Alert

"In the You Be the Coder answer on page 45 of the May general surgery coding Alert, a surgeon sees a patient sent by a primary-care physician (PCP) with what the PCP feels is a palpable breast mass. The mammograms and ultrasound came back negative, and examination revealed no masses and only normal breast tissue. The question was: Which diagnosis code should the surgeon use?

Our answer, 782.2 (localized superficial swelling, mass or lump), has been questioned by some readers, who feel that code 611.72 (lump or mass in breast) would be more appropriate.

Two readers note that immediately below the 782 descriptor (symptoms involving skin and other integumentary tissue), ICD-9 specifically excludes symptoms relating to breast and directs users to codes 611.71-611.79.

Although, at first glance, this might appear to settle the matter, there is a strong case to be made in favor of the original recommendation to use 782.2.

Subtle Distinctions in Definition of Breast

According to the original question, the surgeon never located a lump or mass in or near the breast. The PCP, meanwhile, believed there was a palpable breast mass. Without the patients medical records, it is impossible to know exactly what the PCP saw or felt. It is entirely possible, however, that the palpable mass observed before the patient was referred to the surgeon was in the skin or subcutaneous tissue surrounding the breast, not in the breast tissue itself. By the time the patient saw the surgeon, the mass, wherever and whatever it was, had disappeared, so the surgeon only can speculate as to the nature and/or location of the mass. And although the PCP feels the patient had a palpable breast mass, the patient was sent to a surgeon for verification of that fact, indicating that the PCP clearly was not certain. In any event, because the mass later disappeared, there evidently was good reason for that uncertainty.

All this may seem like hairsplitting, until one examines other sections of the ICD-9 manual that relate to the breast. For example, benign neoplasm of breast (217) specifically excludes skin of breast, which is coded 216.5 (benign neoplasm of skin; breast). Clearly, ICD-9 distinguishes between glandular breast tissue and the skin and subcutaneous tissue that surround the breast.

Given this distinction, it is no more or less appropriate to describe an unknown, unseen mass in the general area of the breast as a localized superficial swelling of the skin or other integumentary tissue (782.2) than as a breast lump (611.72).

Labeling the Patient

Although from a strict coding perspective, 782.2 and 611.72 are equally appropriate in describing the vanished mass in question, 611.72, if used, could harm the patient more. Although both codes fall under the category of signs and symptoms (782.2 is in section 16 symptoms, signs, and ill-defined conditions which contains many, though not all, signs and symptom codes, whereas 611.7 signs and symptoms in breast is the parent category for 611.72), the simple fact remains that 611.72 uses the term breast lump whereas 782.2 does not. And these two words resonate with many private carriers even though 611.72 in no way indicates any kind of tumor, cancer or malignancy. Unfortunately, many carriers will deny coverage on the basis of a pre-existing condition to women who have a breast lump in their medical record, regardless of whether it turned out to be malignant.

Now, if the surgeon had found the mass, palpated it, and determined it was truly a breast lump (i.e., in the tissue of the breast), he or she would have to use 611.72 in spite of concerns about labeling the patient. Of course, if the mass were biopsied, a definitive diagnosis could be used once the pathology report was received.

But in this scenario, with no way of knowing for certain whether the mass was located in the breast tissue or elsewhere, consideration of all the factors tilts the balance in favor of 782.2."