General Surgery Coding Alert

Surgeon intent still matters most for excisions

CPT 2007 creates a whole new subsection dedicated to mastectomy procedures and stocks it with eight new codes (19300-19307). A close look reveals, however, that the changes are far from groundbreaking: The descriptors for 19300-19307 match exactly the descriptors for the familiar (and now outdated) breast excision procedures 19140-19240.

The good news: You won't have to struggle to learn new guidelines when reporting mastectomy procedures, and the new mastectomy codes are more clearly grouped than in the past.

The bad news: CPT 2007 doesn't offer additional clarification on how to differentiate a breast lesion excision from, for example, a partial mastectomy.

Meet the New Codes - Same as the Old Codes

You will find the mastectomy codes following the breast incision (19000-19030), excision (19100-19272) and introduction (19290-19298) subsections. Although the five-digit codes are new, CPT took the descriptors from the now-deleted excision codes 19140-19240, as outlined below:

2007 Code     Deleted             Code Descriptor

19300            (19140)                Mastectomy for gynecomastia

19301            (19160)                Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy)

19302            (19162)                ... with axillary lymphadenectomy

19303            (19180)                Mastectomy, simple, complete

19304            (19182)                Mastectomy, subcutaneous

19305            (19200)                Mastectomy, radical, including pectoral muscles,  axillary lymph nodes

19306            (19220)                Mastectomy, radical, including pectoral muscles,axillary and internal mammary lymph notes (Urban type operation)

19307            (19240)                Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding  major muscle

The intent of the changes seems to be to separate the mastectomy procedures from less-extensive excisions as described by 19100-19272.

-By creating a new subsection and renumbering the codes, the CPT manual becomes better organized and the mastectomy codes easier to find,- says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, S.C. 

Margins Matters for Excision vs. Mastectomy

As in the past, however, you can't look to CPT to give you instructions on when a -mere- breast excision (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, one or more lesions) crosses the line and becomes a partial mastectomy (19301). Instead, you must consider the surgeon's intent when performing the excision and, specifically, whether the surgeon allows for adequate margins around the excised tissue.

In general: If the surgeon removes a breast lesion along with a margin of healthy tissue, you can choose the partial mastectomy code (19301) to describe the procedure, says Donald Keenan, MD, PhD, assistant professor of surgery at the University of Pittsburgh School of Medicine and attending breast surgeon for the Magee-UPCI Breast Program.

There is no specific requirement in CPT that says the margin must be of a specific size to qualify as a partial mastectomy. Rather, the margins must only be -adequate- to ensure that the surgeon removes possible malignant tissue surrounding the excised mass.

-Volume isn't the issue,- Keenan says. Whether the surgeon removes 40 percent of the breast tissue or 15 percent, the procedure may still qualify as a partialmastectomy. -If the surgeon's intent during surgery was to remove a lesion with margins, and this is demonstrated in the operative note, you should choose 19301,- he says.

Don't Rely Too Heavily on Vague Terminology

Never base your code choice on the term -lumpectomy- in the op note. Technically, lumpectomy describes excision of a small, intact tumor -quot; whether cancerous, precancerous or fibroid -quot; but physicians often use the term to describe any excision of breast tissue, regardless of size.

In short: Although -lumpectomy- does appear in the descriptor for 19301, surgeons use the term so widely that, depending on exactly what the physician did, either 19120 or 19301 could apply.

Likewise, 19301's descriptor also includes the terms -tylectomy- and -segmentectomy,- but these terms are also subjective and potentially confusing.

The solution: You should choose a code based on the surgeon's effort to obtain margins around the excised mass rather than based on the terminology the surgeon uses to describe the procedure.

Report 19120 for Minimal Margins

If the surgeon removes only the tumor and no or very little margin, the excision code (19120) is most appropriate.

Watch for -staged- procedures: If the surgeon removes only the lesion with minimal margins (19120), but the pathology report reveals malignancy, the surgeon must return the patient to the operating room and remove additional tissue, Dunaway says. In such a case, you may report the follow-up procedure using the partial mastectomy code (19301) appended with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

Remember: Because the results of the first excision led to the decision to perform the partial mastectomy, you should report both procedures separately, according to CMS guidelines.