19125 vs 19301

nlbarnes

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Escondido, CA
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Dr has coded 19125. The description of the procedure looks like 19125. However, in the "Procedure" up top, it says LT partial mastectomy. I think the report may need to be amended and I will ask him but I wanted feedback before I do.

Procedures: Left partial mastectomy.

Description of the procedure:
After the consent for surgery was verified, the patient was brought to the operating room and placed supine on the operating table. A surgical timeout was completed, general anesthesia administered, preoperative antibiotics administered, sequential compression devices were placed, the bairhugger was placed, and operative field was then prepped and draped in usual sterile fashion.

The patient underwent preoperative wire localization of her tumor with the ultrasound guidance.

Attention was then turned to the left breast. Bovie cautery was used to make a 3 cm radial incision in the left upper quadrant of the breast. The incision was carried down with the help of Bovie cautery until the wire was identified in the wound. The wire was then followed and approximately 5 x 3 x 3 cm cube of tissue was dissected . Adequate hemostasis was noted. The specimen with the wire was then sent to the radiology for intraoperative assessment. The assessment was consistent with adequate positioning of the wireand a biopsy clip within the specimen.

. Visual and digital inspection of the wound was performed,and no abnormalities were identified. The wound was then irrigated with normal saline solution. Surgical hemostasis was insured, was adequate. The wound was then closed with 3-0 Vicryl sutures placed in the deep dermal layer. The skin incision was repaired with 4-0 Monocryl, using subcuticular suture technique. Dermabond dressing was applied.
 

hedmiston

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Route 66 Coders
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I think it should be fine as the description of the procedure matches what he billed. Now if he was trying to bill 19301 and the description of the procedure didn't mention margins, I would query him and have him dictate an addendum.
 

JoannaWelch

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I agree with the 19125. 19301 will mention margins. You should always bill by the body of the op note, not the "title" of procedure performed.
 
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