Wiki Need Input on Coding Excision of Left Breast Cyst and Scar Revision Left Breast Post Breast Reduction. I am coming up with 19120, 11403, 12032

[llewis]

op-note states:
Left breast scar marked for excision, margins were excised, dissection was carried into the subq tissues and this cystic lesion was sent for pathology. The scar of the areola was excised and then the local tissue was used for closure of the areolar wound as well as the vertical wound. Total defect measured 8 cm2. Wound closed in layers.

 

[victoriamoll]

If you look in the instruction for the Repair (Closure) codes in CPT, under Complex repair it states, "Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement...."

I'd veer more towards the 13101, 13102. The CPT Corner articles written by the American Society of Plastic Surgeons also supports the usage of the 1310X series for scar revision. However, the provide did also mention "cystic lesion." What was the final pathology of the specimen?

 

[kathrynw]

Hi,
I would look in the 11400-11406 range, depending on margins and pathology. I would include a code from the 13100-13102 range, again depending on documentation. A Complex repair does not include lesion excision; however, codes from the 13100-13102 range will need a modifier if combined with a code from the 11400-11406 range. Look at mod 59.
I would not recommend 19120 as this code is for excisions in the deep tissues, fascia and muscles. Double check the documentation but above subq is the depth mentioned and this code exceeds that.
Hope this helps,