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Breast Margins

  1. #1
    Default Breast Margins
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    Can anyone tell me if this is adequate documentation of a Breast Margin to give it an 88307 (vs. an 88305)?:

    DIAGNOSIS:
    "BREAST, DEEP MARGIN", (EXCISION):

    - BENIGN BREAST TISSUE SHOWING STROMAL FIBROSIS, DUCT ECTASIA,
    ADENOSIS AND APOCRINE METAPLASIA.
    - NO EVIDENCE OF ATYPICAL INTRADUCTAL HYPERPLASIA OR MALIGNANCY.


    They also will typically only say "The new margin is inked black" in the gross description.

    I see these specimens a lot where I work, and struggle with whether is is adequate documentation that the margins were examined microscopically.

    Thanks!
    Last edited by kate8; 12-16-2009 at 11:20 AM.

  2. #2
    Default
    Per CPT, 88307 is Breast, excision of lesion, requiring microscopic evaluation of margins. The heading of this specimen looks like you've got a seperately submitted margin from the main exicsion.

    While I don't see your microscopic description, I think it's better to say in the diagnosis that the margins were examined for final diagnosis to indicate that that part of the exam was *required* from a CPT standpoint. Especially in a case like this where there's not much going on.

    This looks like 88305 to me.

  3. Default
    I agree , this looks like they just looked at a margin and not a lesion.
    I would code this as 88305 also

  4. #4
    Smile
    Per CPT, 88307 is Breast, excision of lesion, requiring microscopic evaluation of margins. The heading of this specimen looks like you've got a seperately submitted margin from the main exicsion.


    Yes, we get a lot of these Margins with a Breast Excision/Mastectomy, and they are submitted as a separate speciemen from the Breast Excision. I've had some push-back from pathologists about whether this documentation is worthy of an 88307. I have been coding them as 88305 unless they have an actual measurement of how close a lesion may be to the margin in the Margin specimen. Thanks for your replies - I'm relieved I interpreted the codes correctly!

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