General Surgery Coding Alert

Question:

Ohio Subscriber

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 19301 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]). CPT instruction for the breast excision codes states, "the open excision of breast lesions ..., without specific attention to adequate surgical margins ... is reported using codes 19110-19126." In contrast, the instructions note that, "documentation for partial mastectomy procedures [19301, 19302] includes attention to the removal of adequate surgical margins surrounding the breast mass or lesion."

Optimal documentation: If the surgeon performs a partial mastectomy, the op note should ideally identify the procedure as such, or use another specific procedure descriptor such as lumpectomy, tylectomy, etc. The surgeon should also document the attempt to excise clear margins with a statement in the op note such as, "special attention was paid to ensure adequate margins."