codedog
True Blue
I always thought if doctor states excisional biopsy he/she is taking the entire lesion/mass out. Another coder disagrees with me stating a biopsy is a biopsy and itit states biosy could it as a biopsy . Not sure if I agree. Here is an example
I say this is 19120 while other coder says this is 19101- biopsy
PREOPERATIVE DIAGNOSIS: Right breast mass.
POSTOPERATIVE DIAGNOSIS: Right breast mass.
PROCEDURE PERFORMED: Excisional biopsy of right breast mass.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: patient with an area on upper aspect of areola that has repeatedly become infected and has recurred despite the incision and drainage.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on operating room table in supine position. The right breast was prepped and draped in sterile fashion. An elliptical incision was made on the upper aspect of the right areola. Sharp dissection was used to dissect through the subcutaneous tissue to excise the mass, which was immediately beneath the skin. The implant was not visualized during the procedure. There was no purulence. The mass was completely resected with grossly negative margins. The wound was irrigated first with Betadine and then with normal saline. It was inspected and found to be hemostatic. The skin was closed with interrupted 3-0 nylon sutures. A sterile dressing was applied. The patient tolerated the procedure well.
I say this is 19120 while other coder says this is 19101- biopsy
PREOPERATIVE DIAGNOSIS: Right breast mass.
POSTOPERATIVE DIAGNOSIS: Right breast mass.
PROCEDURE PERFORMED: Excisional biopsy of right breast mass.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: patient with an area on upper aspect of areola that has repeatedly become infected and has recurred despite the incision and drainage.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on operating room table in supine position. The right breast was prepped and draped in sterile fashion. An elliptical incision was made on the upper aspect of the right areola. Sharp dissection was used to dissect through the subcutaneous tissue to excise the mass, which was immediately beneath the skin. The implant was not visualized during the procedure. There was no purulence. The mass was completely resected with grossly negative margins. The wound was irrigated first with Betadine and then with normal saline. It was inspected and found to be hemostatic. The skin was closed with interrupted 3-0 nylon sutures. A sterile dressing was applied. The patient tolerated the procedure well.
