Wiki Needle localised lumpectomy

[kajalgaonkar16]

Need help in deciding whether to code 19125 or 19301 in this case!

DIAGNOSIS- intraductal papilloma
PROCEDURE: left breast needle localised lumpectomy

Patient was brought to the operating room laid supine on the operating table. LMA was placed general anesthesia was administered.
She underwent a needle localization prior to being brought to the operating room. The films were seen and reviewed.
Left breast and axilla was prepped and draped in a sterile fashion and timeout was called. Skin incision made with a 10 blade superior and inferior flaps were raised to keep the needle in the center of the lumpectomy. The lumpectomy was carried out down to the muscle inferiorly this was then marked with short stitch superior long stitch lateral and placed in the Faxitron to check that both the needle and the clip and the marker was in the center of the specimen once this was confirmed, this was sent off to pathology as routine.
Hemostasis was achieved. Skin was closed with 3-0 Vicryl deep dermal sutures 4-0 Monocryl subcuticular suture and Steri-Strips were applied sterile dressing placed. Patient was extubated transferred to recovery room in a stable fashion swab and needle count was correct ×3 at the end of the procedure.

 

[haraml7]

My first question would be, "was there specific attention to margins?" I would ask this because our CPT guidelines show that the difference between 19125 and 19301 would be if there was specific attention to margins.

The documentation that was posted is a little vague in specifying margins as it says" check that both the needle and the clip and the marker was in the center of the specimen" and he cut down to the muscle.

If the provider stated in the documentation "specifying margins" this would change your coding.

The CPT guidelines on pg 105 states this information I have provided.