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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 11:21 AM.

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