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Thread: How would you code this?

  1. #1
    Join Date
    Apr 2007

    Question How would you code this?

    AAPC: Back to School
    I am leaving out some of the extras that won't have anything to do the decision. Here is what the operative note reads:
    Procedure: 1.Left breast wire localized lumpectomy/partial mastectomy
    2.Left axillary sentinel lymph node biopsy
    Peroperatively, the patient had been to Radiology where a wire was placed under ultrasound guidance into the left breast in the area of the abnormatlity. The patient also had technetium placed for assistance with the sentinel lymph node biopsy.
    A Geiger counter was used intraoperatively in a steril fashion. An area of elevated activity was noted and, therefore, the incision was made in that location. The axilla was entered. With careful dissection and using a Geiger count as a guide, a single blue lymph node was identified, which had elevated radioactive counts. This lymph node was removed.
    Attention was then turned towards the left breast. Again, local anesthetic was used and a 4.5 cm incision was made in the lateral portion of the breast near the wire. The skin flaps were raised circumferentially around this incision and the wire was internalized into the wound. With careful dissection circumferentially around the area of the wire, a segment of breast tissue was removed. A palpable mass was present within the excised breast tissue. The specimen was then tagged with a long stitch laterally and a short stitch superiorly. The specimen was pass off the field.
    The rest is about the closure.
    There is a debate in our office as to how to appropriately code this. Can someone weigh in on this?

  2. #2


    You did not give a diagnosis but in this case it is most likely cancer. Once a patient has a diagnosis of cancer generally you are looking at the codes in the 193-- section. Just because a wire may be inserted does not necessarily make the code always 19125. Very often wires are placed for a partial mastectomy. Once a patient has cancer the physician is taking larger margins wider excision around the wire. In 19125 they are just taking the wire and a very tiny margin around the wire. Hope that helps you out.

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