Breast Margins

[kate8]

Can anyone tell me if this is adequate documentation of a Breast Margin to give it an 88307 (vs. an 88305)?:

DIAGNOSIS:
"BREAST, DEEP MARGIN", (EXCISION):

- BENIGN BREAST TISSUE SHOWING STROMAL FIBROSIS, DUCT ECTASIA,
ADENOSIS AND APOCRINE METAPLASIA.
- NO EVIDENCE OF ATYPICAL INTRADUCTAL HYPERPLASIA OR MALIGNANCY.


They also will typically only say "The new margin is inked black" in the gross description.

I see these specimens a lot where I work, and struggle with whether is is adequate documentation that the margins were examined microscopically.

Thanks!

 

[whaleheadking]

Per CPT, 88307 is Breast, excision of lesion, requiring microscopic evaluation of margins. The heading of this specimen looks like you've got a seperately submitted margin from the main exicsion.

While I don't see your microscopic description, I think it's better to say in the diagnosis that the margins were examined for final diagnosis to indicate that that part of the exam was *required* from a CPT standpoint. Especially in a case like this where there's not much going on.

This looks like 88305 to me.

 

[mannlx]

I agree , this looks like they just looked at a margin and not a lesion.
I would code this as 88305 also

 

[kate8]

Per CPT, 88307 is Breast, excision of lesion, requiring microscopic evaluation of margins. The heading of this specimen looks like you've got a seperately submitted margin from the main exicsion.

Yes, we get a lot of these Margins with a Breast Excision/Mastectomy, and they are submitted as a separate speciemen from the Breast Excision. I've had some push-back from pathologists about whether this documentation is worthy of an 88307. I have been coding them as 88305 unless they have an actual measurement of how close a lesion may be to the margin in the Margin specimen. Thanks for your replies - I'm relieved I interpreted the codes correctly!