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19301 vs 19125

  1. #1
    Default 19301 vs 19125
    Medical Coding Books
    IF doc does a needle loc breast biopsy-19125 and states if was dissected free of surrounding breast tissue and all margins were grossly negatives .do does ths clarify 19301
    Last edited by codedog; 09-21-2011 at 06:45 PM.

  2. #2
    here is operative report, i dont see anything about margins -so 19125 ?or 19301

    PROCEDURE PERFORMED: Right needle localization breast biopsy.

    PROCEDURE IN DETAIL: 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 laryngeal mask. Her right breast was prepped and draped in normal fashion. The films had been reviewed by me in the operating room. The wire was left in the patient. An incision was made around the wire. Dissection was carried down through the skin and subcutaneous tissue. The entire wire with surrounding tissue was removed and sent to Radiology. It did confirm after reviewing the ultrasound we had lesioning done on the patient. In the interim, two other small pieces were taken and sent to pathology. Because the initial thing was that we did not have the specimen, when we reviewed again it came back says we did have the specimen. Therefore, these two specimens did not need to go to Radiology, but went to pathology. Excellent hemostasis was noted to be obtained. The wound was closed in 3-0 Vicryl, applied 3-0 nylon in a simple interrupted fashion. Sterile dressing was placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.

  3. Default
    I only read documentation to support 19125. In 19301, a malignant lesion/tumor is removed with surrounding tissue. Is there a malignancy present?
    Last edited by lovetocode; 09-23-2011 at 06:32 AM.

  4. Default
    I don't think you have to use a malignancy diagnosis to code 19301. I think you should use 19125 because the only reason they took the two extra specimens is because they did not think they had their localization wire I do not think it was because they were paying close attention to the margins. I hope this helps.

  5. #5
    yes thanks

  6. Default
    In reading the description for code 19301, it states the physician excises a breast tumor and a margin of normal tissue by performing a partial mastectomy by making an incision through the skin and fascia over a breast malignancy and clamping any lymphatic and blood vessels. The physician excises the mass along with a margin or rim of healthy tissue. This procedure is often referred to as a segmental mastectomy or a quadrantectomy, but is also called a lumpectomy.

  7. Question General Surgery Coder
    What about when there's a preop dx of malignancy, there's a wire present, BUT he also documents "grossly clear margins were obtained?" 19301 or 19125?
    1. Left breast carcinoma in situ.

    1. Left breast carcinoma in situ. Pathology pending.

    PROCEDURE: Needle localization, left breast excisional biopsy and
    node biopsy.

    1. General.

    FINDINGS AT SURGERY: Specimen x-ray revealed that the area in question
    been removed. The pathologist came to the operating room and suggested
    that the margins were grossly clear. Final pathology pending.

    OPERATIVE REPORT: Once satisfactory anesthesia was obtained the patient
    was prepped with Betadine and draped in usual manner for surgery.
    Curvilinear incision was made in the upper outer quadrant of the left
    breast adjacent to the previously placed wire for localization and a skin
    incision was made and the skin flaps were raised. Generous biopsy taken
    the underlying tissue and needle tract down to the chest wall and specimen
    x-ray was obtained when the specimen was removed. It was satisfactory.
    The area in questions had been removed and the findings were as stated
    pathology in the operating room. Gross margins were clear. Final
    pathology pending. Specimen was labeled and sent to Pathology. The
    incision was then extended into the axilla. The counter probe was used.
    The sentinel node tissue was noted and was dissected free from surrounding
    tissue. Care taken to identify the left axillary vein and nerves in the
    canal. The sentinel node tissue was removed, labeled and sent to
    Pathology. The wound was inspected. Hemostasis was obtained. No other
    suspicious areas were noted and the wound was closed. A Jackson-Pratt
    drain was placed through separate stab wound incision and the wound closed
    in layers with 3-0 Vicryl, subcuticular 4-0 Vicryl for the skin. Dilute
    Marcaine was infiltrated around the incision prior to closure. Dressing
    placed over the wound. Surgery was terminated. Estimated blood loss less
    than 50 cc. Case was clean. Lap, sponge, instrument and needle counts
    correct following termination of the procedure.

    I would appreciate any help on this!

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