General Surgery Coding Alert

Question: The patient's pre-op diagnosis is "breast mass." The op report states, "superficial mass excised for a length of 1.4 cm x 1.1 cm with layered closure." The pathology report states, "ruptured epidermoid cyst/pustular folliculitis." Is 19120 the correct procedure code?

Georgia Subscriber

Answer: The correct procedure code is 11402 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 1.1 to 2.0 cm) Based on the pathology report, the patient had a skin lesion that you would report as 706.2 (Sebaceous cyst). Although you have an initial diagnosis of "breast mass" and a final diagnosis described as a cyst, this is not a breast cyst, such as 610.0 (Solitary cyst of breast).

Because the operative note states that the mass is "superficial" and the diagnosis states that the lesion is in the epidermis, you should not report the code for excision of a breast cyst. In other words, 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) is not the correct code for this procedure.