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please help- coding question

  1. #1
    Question please help- coding question
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    Inspection: symmetrical, nipple discharge normal milk, left breast nipple with lateral raised whitened clogged gland. disc options of monitoring vs trying to drain and risk with draining for infection and for it to return. wants to try to drain it.
    Numbed with lidocaine gel, cleaned with alcohol swabs and inserted fine gauge syringe laterally to make X over the center of gland. Expressed large amount of white cheesy substance. No evidence of infection. tolerated well. Reduced to normal pink nipple, no dimpling.

    Please help me find a cpt code.
    i was looing at 19112 but i am not sure.


  2. #2
    I don't think I would use 19112, that is an excision.

    Lay Description of 19112

    The physician makes an incision around the abnormal opening of a lactiferous duct fistula on the skin. The fistula is dissected down to the duct. The duct, fistula, and skin opening are all excised. The remaining portion of the duct may be ligated. The wound is irrigated with warm sterile saline and closed in layers.

    19000 seems more like what was done but since it wasn't a cyst I really don't know. I would probably go with 10060 personally.

    Sorry not much help,

    Laura, CPC, CPMA, CEMC

  3. #3
    i didnt look at 10060 codes .......... thanks for your help.

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