19301 vs 19295?

ksb0211

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Just wondering what others thought about this case. The surgeon was originally planning on performing a lumpectomy (19301). After reading the operative report, I'm wondering if that should now be changed to 19295. What are your thoughts?

Thanks.

PREOPERATIVE DIAGNOSIS
Left breast carcinoma stage 3B.

POSTOPERATIVE DIAGNOSIS
Left breast carcinoma stage 3B.

PROCEDURE
Lumpectomy.

PROCEDURE
The patient was brought to the operating room. After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. We made an incision adjacent to the needle localization wire, removed a core of tissue involving this wire as well. This was a large tumor and as we began to dissect the tumor there was a lot of indurated material that was clinically suspicious as we came up behind the areolar complex. We came back behind the areolar complex and basically skeletonized this material away. We could see that this area of induration moved across the breast over to the far border and clinically it was suspicious. Removal of anymore of this tissue was going to just absolutely just remove her breast as a subcutaneous mastectomy. We elected just to leave it at that point. We took it out, marked the areas carefully, called pathology and told them what our concerns were about this tumor being more extensive than we had anticipated. I would like to add that we thought preoperatively that it was a big tumor over 5 cm. Once we resected all this area, took it off the wall of the pectoralis and into the axilla to some small extent. We had removed what we felt was a tumor along with the needle localization wire, but we felt that ultimately our concerns with that we were not going to be able to get an adequate amount of margins on this patient. We elected not to do shaves because the area that we left behind remained clinically suspicious and widely so. Once that was done, we irrigated the area, closed with deep sutures of 4-0 Vicryl followed by running subcuticular suture of 4-0 Vicryl, filled the compartment of the lumpectomy with about 15 mL maybe 18 mL of Marcaine. We then used surgical adhesive over that area. The patient tolerated the procedure quite well.
 

Bwray

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I would have used CPT 19125 due to the fact the surgeon did not remove the tumor and additional tissue to the point of clean margins.
 

surgonc87

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Atlanta
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Clean margins? I don't see in the book that it states it has to have clean margins. The book says attention to clean margins. The intent were to rid of all of the cancer with adequate margins, it was incidental that the tumor was more extensive then they had anticipated. Its important to also pay attention to actual work done and mental work into a procedure instead of coding A or B. Either way it should be fair for the surgeons work. Its ultimately up to the coder working the case to see what's defendable from their point of view. Either one can go, but why minimize it.


I would have used CPT 19125 due to the fact the surgeon did not remove the tumor and additional tissue to the point of clean margins.
 
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