More clarification of 19301 vs 19125

Artesia, NM
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I am looking at multiple op reports where there is needle localization, clearly documented in the op report and a radiologist report, where the surgeon does a "deep dissection" around the needle/wire and completely excises the tissue and wire and it is sent to radiology for confirmation that tissue in question is around the wire.

Sometimes the surgeon says, "the lump is around the wire", sometimes he says "the mass is around the wire" and sometimes he says "the segment of area was removed around the wire".

There are times, after the initial dissection that the surgeon will document that he removes excess tissue to get clean margins, but this is after the original tissue in question has been sent to radiology.

So because he uses different words to described what he is excising and then sometimes documents he continues dissection to get clean margins, I am totally confused as to whether this constitutes and 19301 or a 19125. Since 19301 does not mention the use of any type of localization technique, guide wire or needle, I feel these should be coded as 19125. I also believe that is the right code since the margins are done after the tissue has already been sent to radiology and is not being described as "focus was made to margins" during the original procedure.

Any help you can give me is greatly appreciated!!!

Stacy Carlile:confused:


Best answers
19125 always has a wire loc
19301 may or may not have a wire loc

19125 is just the lesion in question and no other tissue
19301 includes more tissue to get clean margins.

When it comes to him excising more tissue after he removes the lesion w/ wire loc he needs to let you know in the procedure name if he took out enough extra tissue for it to be considered a partial or just a little bit and it's still considered a 19125. Only he knows exactly how much tissue he excised.