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help with breast procedure

  1. Default help with breast procedure
    Medical Coding Books
    I am billing for ASC but not very familiar with breast procedures, please help with the following;

    patient had an elliptical incision around the area of the previous infection and this was then directed down through and underneath the left nipple areola. A ignificant area of epithelium and secondary skin was noted in the site and this tissue iteself was biopsied and then sent off for direct culture. Culture included Mycoplasma and Mycobaterium. The patient then had the incision trapped and elevation of the entire left nipple areola. It was noted that the inflmmatory process extended across the left nipple infra areola area up into the uper breast. With this noted, the patient then had the skin freed completely around the left breast and then tracking the infection noted that extended down to the pectoralis fascia. The left breast tissue removed in a simple mastectomy technique. The tissue was completely submitted for pathology and then after removal, the patient had the surgical site irrigated with peroxide, betadine and saline. the patient then had the subcutaneous tissues secured to the underlying muscle with multiple sutures of 3-0 chromic and then a 7mm drain placed under the area of closure.

    HISTORY: patient has a history of E. coli infection since 10/2008, and since this infection the area of the sinus tract will be excised as well as the underlying tissue that has the offending organism. & pathology report came back with recurrent abscess left chest.

    im thinking maybe 19120 & 19303???

    Thank you

  2. #2
    I would code 19303; 19120 is included per CCI but you can also override it with a 59 modifier.

  3. #3
    I think I would check with the surgeon to find out exactly how much of the tissue was removed before using 19303. It doesnt sound like he removed ALL of the subcutaneous tissue for a COMPLETE mastectomy. To me it sounds as if he only removed the sinus tract portion.

  4. Default

    You guys are great!!!

  5. #5
    Better to ask for the surgeon for the path of the breast tissue excised.
    in path u will find how much whole tissue of breast was excised, if this turns out major portion of breast.
    Then u can easily code it to 19303 without 19120
    there is no need to code 19120 with 19303 as it (19120) is inclusive to 19303.
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