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19125 vs 19301

  1. #1
    Default 19125 vs 19301
    Medical Coding Books
    i say this this report should be coded as 19125 ,my boss wants me to code it as 19301. I know 19301 has something to do with the margins , but I dont see where it isin report, does any see where this can be 19301, it so please tell me why -thanks , 19125 seems right to me.- o by the way path report came back as infiltrating ductal carcinoma - had a note on it that read - carcinoma is present at inked margin of excision

    POSTOPERATIVE DIAGNOSIS: Left breast mass.
    OPERATION: Left needle localization breast biopsy with specimen around 5 cm circumscribed.
    After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, and underwent general anesthesia with successful endotracheal intubation. The patient was examined by me in the preoperative holding area and gone to Radiology and had a left needle placed via mammography. The covering was removed. The wire was kept in place and left breast was prepped and draped in normal fashion. The patient had received preoperative antibiotics prior to skin incision. An incision over the wire including the mastectomy incision was made for around 5 to 6 cm. Dissection was carried down through the skin and subcutaneous tissue. The entire wire with surrounding tissues for around 4 to 5 cm was removed with the entire wire. This was done with Bovie cauterization. Specimen was removed and sent to Radiology, and they confirmed that we did have the area of interest, that it was not in the patient and was in the specimen that was removed. After getting confirmation that we successfully removed the specimen via needle localization, the wound was irrigated. There was noted to be excellent hemostasis. Subdermals were closed with 3-0 Vicryl interrupted and subcuticular closed with 4-0 Vicryl running in a subcuticular fashion. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
    Last edited by codedog; 06-07-2011 at 11:28 AM.

  2. #2
    Default 19301
    19125 is without attention to margins

    19301 is with attention to margins

    Per Ingenix Coding Companion for General Surgery

    Hope that helps...

  3. #3
    is surrounding tissue the margins ? i dont think so, but not sure

  4. #4
    Default surrounding tissue
    Yes, the surrounding tissue is the margin.
    19125 vs. 19301
    Use 19301 when the doc is obtaining NEW margins, so even if the wire is present and the doc resects the wire, but in the process is obtaining new clean margins I use 19301. If the doc just removes the wire specimen but pays no attention to margins, use 19125

  5. #5

  6. #6
    I agree with 19301!

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