Incisional biopsy of nipple

[codedog]

Operative report says Incisional biopsy of nipple but closest code come to would be 19101 , would this be right ?

 

[syllingk]

Need a little more info.

What were they excising? Excising a nipple or areolar lesion would be 19120. Or look at 19110. Did they place a wire loc? Then it would be 19125.

 

[codedog]

here is report , wanted to use 19120 but its seems it just looks like biopsy , what do you think ?



PREOPERATIVE DIAGNOSIS: Right nipple inversion.

POSTOPERATIVE DIAGNOSIS: Right nipple inversion.

PROCEDURE PERFORMED: Incisional biopsy of right nipple.

ANESTHESIA: MAC.

ESTIMATED BLOOD LOSS: Minimal.

CLINICAL HISTORY: patient seen in my office with new onset of right nipple inversion. There were no mammographically detectable lesions. The ductogram revealed no significant abnormality. The area only improved slightly with antibiotic and topical medicines and she has consented for biopsy to rule out a malignancy.

PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating table in a supine position. The right breast was prepped and draped in sterile fashion. 10 cc of 1% lidocaine with epinephrine was injected for local anesthesia. A scalp was used to excise a 2 mm segment of the _____ (01:02) portion of the nipple, which was inverted and involved in the erythematous rash involving the skin in this area. Hemostasis was easily achieved with electrocautery and the skin was easily re-approximated with two 4-0 nylon sutures. A sterile dressing was applied. The patient tolerated the procedure well.

19120 ?

 

[codedog]

doctor said it was an incisional biopsy, still there is no code for this

 

[syllingk]

What did the pathology come back as?

 

[codedog]

sebaceous gland hyperplasia

 

[syllingk]

Gosh this is a hard one since they didn't excise the whole thing and there aren't any unlisted codes to fall back to in this category.

I am thinking 11100. Anyone else have any opinions?

 

[nsteinhauser]

When you read the lay descriptions for 19101 and 19120 - the 19101 seems like a more accurate fit because he didn't 'remove' the 'lesion' or 'aberrant breast tissue' ....he just took a biopsy of it....so I'm leaning towards 19101....

 

[syllingk]

19101 Explanation (and I do agree this is probably the best code)
The physician removes tissue for biopsy. The physician makes an incision in the skin of the breast near the site of the supspect mass. the mass is identified and a sample of the lesion removed. This specimen is often examined immediately. If the lesion is benign, the incision is repaired with layered closure. If malignant, the incision may be closed pending a separate, more extensive surgical session. or a more extensive surgery may occur emmediately, in which case this code would not be reported. and under the covered dx's it does list some codes with nipple.

 

[codedog]

thank you both, 19101 it is, thanks, one less gray hair -lol