• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Needle localized excisional biopsy

Create Wiki
L

laura_clffrd@yahoo.com

Networker
Messages
59
Location
Lewiston, Maine
Best answers
0
Any suggestions for a 71 year old Female had a mammotome biopsy showing atypical ductal hyperplasia of that biopsy. Two needles were placed in the x-ray department, identified surrounding a density and also previous clip in right breast. an incision was made between the 2 needles through to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the needles. Would it be 19125?
 
If the surgeon did not take the whole mass/lesion it would not be 19125.
Please post a scrubbed OP note as the original statement does not have enough information to code.
 
incision was made between the 2 needles. the incision was carried to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the 2 needles. this was then sent to radiology with with confirmation, the clip was removed and the density removed. hemostasis was achieved with bovie electrocoagulation. deep subcutaneous tissue was then reapproximated with a running vicryl suture and the skin was reapproximated with running subcuticular stitch.

any suggestions on learning material would be great as well. I recently started a new position and worked radiology before... so surgery and e/m is a little more challenging. This is also a new client so I think the documentation guidelines needs to be reviewed with them as well. I recently ordered the surgery book from aapc and will order the e/m family practice next paycheck. Any additional ideas would be great!
 
From the statement that "the density was removed" I guess an argument could be made that the entire mass/lesion was removed. I have to admit I would query the physician as to whether or not the whole mass/lesion was removed and ask for a corrected OP note but that's just how I do it.
If the whole thing was removed it would be 19125.
I have the Ingenix General surgery coding companion and I love it! It goes into a more in depth description of procedures so that I can compare them to the OP notes to see if the surgery performed meets the criteria of the code I am looking at :D
 
You must log in or register to reply here.
Top