codedog
True Blue
IF doc does a needle loc breast biopsy-19125 and states if was dissected free of surrounding breast tissue and all margins were grossly negatives .do does ths clarify 19301
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Wiki 19301 vs 19125
- Thread starter codedog
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codedog
True Blue
here is operative report, i dont see anything about margins -so 19125 ?or 19301
PROCEDURE PERFORMED: Right needle localization breast biopsy.
PROCEDURE IN DETAIL: After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table and underwent general anesthesia with laryngeal mask. Her right breast was prepped and draped in normal fashion. The films had been reviewed by me in the operating room. The wire was left in the patient. An incision was made around the wire. Dissection was carried down through the skin and subcutaneous tissue. The entire wire with surrounding tissue was removed and sent to Radiology. It did confirm after reviewing the ultrasound we had lesioning done on the patient. In the interim, two other small pieces were taken and sent to pathology. Because the initial thing was that we did not have the specimen, when we reviewed again it came back says we did have the specimen. Therefore, these two specimens did not need to go to Radiology, but went to pathology. Excellent hemostasis was noted to be obtained. The wound was closed in 3-0 Vicryl, applied 3-0 nylon in a simple interrupted fashion. Sterile dressing was placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
PROCEDURE PERFORMED: Right needle localization breast biopsy.
PROCEDURE IN DETAIL: After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table and underwent general anesthesia with laryngeal mask. Her right breast was prepped and draped in normal fashion. The films had been reviewed by me in the operating room. The wire was left in the patient. An incision was made around the wire. Dissection was carried down through the skin and subcutaneous tissue. The entire wire with surrounding tissue was removed and sent to Radiology. It did confirm after reviewing the ultrasound we had lesioning done on the patient. In the interim, two other small pieces were taken and sent to pathology. Because the initial thing was that we did not have the specimen, when we reviewed again it came back says we did have the specimen. Therefore, these two specimens did not need to go to Radiology, but went to pathology. Excellent hemostasis was noted to be obtained. The wound was closed in 3-0 Vicryl, applied 3-0 nylon in a simple interrupted fashion. Sterile dressing was placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
lovetocode
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I only read documentation to support 19125. In 19301, a malignant lesion/tumor is removed with surrounding tissue. Is there a malignancy present?
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tcooper@nmhs.net
Networker
I don't think you have to use a malignancy diagnosis to code 19301. I think you should use 19125 because the only reason they took the two extra specimens is because they did not think they had their localization wire I do not think it was because they were paying close attention to the margins. I hope this helps. 
codedog
True Blue
yes thanks
lovetocode
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In reading the description for code 19301, it states the physician excises a breast tumor and a margin of normal tissue by performing a partial mastectomy by making an incision through the skin and fascia over a breast malignancy and clamping any lymphatic and blood vessels. The physician excises the mass along with a margin or rim of healthy tissue. This procedure is often referred to as a segmental mastectomy or a quadrantectomy, but is also called a lumpectomy.
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General Surgery Coder
What about when there's a preop dx of malignancy, there's a wire present, BUT he also documents "grossly clear margins were obtained?" 19301 or 19125?
PREOPERATIVE DIAGNOSIS:
1. Left breast carcinoma in situ.
POSTOPERATIVE DIAGNOSIS:
1. Left breast carcinoma in situ. Pathology pending.
PROCEDURE: Needle localization, left breast excisional biopsy and
sentinel
node biopsy.
ANESTHESIA:
1. General.
FINDINGS AT SURGERY: Specimen x-ray revealed that the area in question
had
been removed. The pathologist came to the operating room and suggested
that the margins were grossly clear. Final pathology pending.
OPERATIVE REPORT: Once satisfactory anesthesia was obtained the patient
was prepped with Betadine and draped in usual manner for surgery.
Curvilinear incision was made in the upper outer quadrant of the left
breast adjacent to the previously placed wire for localization and a skin
incision was made and the skin flaps were raised. Generous biopsy taken
of
the underlying tissue and needle tract down to the chest wall and specimen
x-ray was obtained when the specimen was removed. It was satisfactory.
The area in questions had been removed and the findings were as stated
from
pathology in the operating room. Gross margins were clear. Final
pathology pending. Specimen was labeled and sent to Pathology. The
incision was then extended into the axilla. The counter probe was used.
The sentinel node tissue was noted and was dissected free from surrounding
tissue. Care taken to identify the left axillary vein and nerves in the
canal. The sentinel node tissue was removed, labeled and sent to
Pathology. The wound was inspected. Hemostasis was obtained. No other
suspicious areas were noted and the wound was closed. A Jackson-Pratt
drain was placed through separate stab wound incision and the wound closed
in layers with 3-0 Vicryl, subcuticular 4-0 Vicryl for the skin. Dilute
Marcaine was infiltrated around the incision prior to closure. Dressing
placed over the wound. Surgery was terminated. Estimated blood loss less
than 50 cc. Case was clean. Lap, sponge, instrument and needle counts
correct following termination of the procedure.
I would appreciate any help on this!
What about when there's a preop dx of malignancy, there's a wire present, BUT he also documents "grossly clear margins were obtained?" 19301 or 19125?
PREOPERATIVE DIAGNOSIS:
1. Left breast carcinoma in situ.
POSTOPERATIVE DIAGNOSIS:
1. Left breast carcinoma in situ. Pathology pending.
PROCEDURE: Needle localization, left breast excisional biopsy and
sentinel
node biopsy.
ANESTHESIA:
1. General.
FINDINGS AT SURGERY: Specimen x-ray revealed that the area in question
had
been removed. The pathologist came to the operating room and suggested
that the margins were grossly clear. Final pathology pending.
OPERATIVE REPORT: Once satisfactory anesthesia was obtained the patient
was prepped with Betadine and draped in usual manner for surgery.
Curvilinear incision was made in the upper outer quadrant of the left
breast adjacent to the previously placed wire for localization and a skin
incision was made and the skin flaps were raised. Generous biopsy taken
of
the underlying tissue and needle tract down to the chest wall and specimen
x-ray was obtained when the specimen was removed. It was satisfactory.
The area in questions had been removed and the findings were as stated
from
pathology in the operating room. Gross margins were clear. Final
pathology pending. Specimen was labeled and sent to Pathology. The
incision was then extended into the axilla. The counter probe was used.
The sentinel node tissue was noted and was dissected free from surrounding
tissue. Care taken to identify the left axillary vein and nerves in the
canal. The sentinel node tissue was removed, labeled and sent to
Pathology. The wound was inspected. Hemostasis was obtained. No other
suspicious areas were noted and the wound was closed. A Jackson-Pratt
drain was placed through separate stab wound incision and the wound closed
in layers with 3-0 Vicryl, subcuticular 4-0 Vicryl for the skin. Dilute
Marcaine was infiltrated around the incision prior to closure. Dressing
placed over the wound. Surgery was terminated. Estimated blood loss less
than 50 cc. Case was clean. Lap, sponge, instrument and needle counts
correct following termination of the procedure.
I would appreciate any help on this!