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Breast mass

  1. #1
    Default Breast mass
    Medical Coding Books
    Can a breast mass be coded in the 1140x area ? Reason why I ask is because this patient is a male and pathlogy report came back as an epidermal inclusion cyst. Doctor stated on postoperative report that it was a mass .
    He went on saying in operative report that it was a chest wall mass with an incision was made directly over the mass which then be appeared to be an epidermal cyst. IT did state dissection was carried down through the skin and subcutaneous tissue. He then stated that the entire mass with surrounding filmy white cheesy substance including the sac was removed with surrounding fat.

    SO i want to code 19120 but something tells me to go to go to 1140x ? any ideas ?

  2. #2
    Milwaukee WI
    Default 19120
    Lay description from Encoder Pro for 19120 is: The physician excises breast tissue for biopsy. The physician makes an incision in the skin of the breast overlying the site of the mass. Skin and tissue are dissected from the site of the defective tissue. The lesion is removed without attention to obtaining clean margins. Bleeding vessels are controlled with electrocautery or ligated with sutures. A drain may be inserted into the wound. The incision is sutured in layered closure and a light pressure dressing is applied.

    If this matches your op report then 19120 is the correct code to use.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    also remember, do not base your CPT code on the results of the pathology report. Base it upon how the procedure is performed.
    Mary, CPC, CANPC, COSC

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