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19301 or 19125

  1. #1
    Location
    NEW ORLEANS
    Posts
    954
    Default 19301 or 19125
    Exam Training Packages
    2 coders conflict
    I think this procedure should be coded as 19125 , other co worker says its 19301 because of surrounding tissue removed 4 to 5 cm. .Who is right ?

    POSTOPERATIVE DIAGNOSIS: Left breast mass via mammography.
    OPERATION: Left needle localization breast biopsy.
    .
    PROCEDURE IN DETAIL:
    After appropriate informed consent was signed, the patient was taken to the operating room, transferred to the operating table and underwent general anesthesia with successful laryngeal mask. The left breast was prepped and draped in the normal fashion. After the patient had a wire placed by Radiology and informed consent was reviewed by me prior to making a skin incision. Incision directly over the wire was made. Dissection was carried down through the skin and subcutaneous tissue. The entire wire with surrounding tissue was removed for around 4 to 5 cm. It was sent to Radiology. They confirmed that we did have the specimen that was out of the patient and it was in the wire that was removed. Excellent hemostasis was noted to be obtained. The wound was closed in two layers, 3-0 Vicryl in subdermal and 4-0 Vicryl in subcuticular fashion. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure and transferred to the recovery in stable condition.

  2. #2
    Location
    Columbia, MO
    Posts
    12,570
    Default
    I am leaning toward the 19125 even with the surrounding tissue. 19125 is removal of the lesion without attention to obtaining clean margins. I do not see the attention to obtaining clean margins in the note, just care to get as much of the lesion as possible.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    NEW ORLEANS
    Posts
    954
    Default
    thank you Debra

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