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Needle localized excisional biopsy

  1. #1
    Default Needle localized excisional biopsy
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    Any suggestions for a 71 year old Female had a mammotome biopsy showing atypical ductal hyperplasia of that biopsy. Two needles were placed in the x-ray department, identified surrounding a density and also previous clip in right breast. an incision was made between the 2 needles through to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the needles. Would it be 19125?

  2. Default
    Yep, 19125.

  3. #3
    Location
    Fayetteville, NC
    Posts
    300
    Default
    If the surgeon did not take the whole mass/lesion it would not be 19125.
    Please post a scrubbed OP note as the original statement does not have enough information to code.
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  4. #4
    Default
    incision was made between the 2 needles. the incision was carried to subcutaneous tissue and taken in the direction of the needle encompassing a generous amount of tissue between the 2 needles. this was then sent to radiology with with confirmation, the clip was removed and the density removed. hemostasis was achieved with bovie electrocoagulation. deep subcutaneous tissue was then reapproximated with a running vicryl suture and the skin was reapproximated with running subcuticular stitch.

    any suggestions on learning material would be great as well. I recently started a new position and worked radiology before... so surgery and e/m is a little more challenging. This is also a new client so I think the documentation guidelines needs to be reviewed with them as well. I recently ordered the surgery book from aapc and will order the e/m family practice next paycheck. Any additional ideas would be great!

  5. #5
    Location
    Fayetteville, NC
    Posts
    300
    Default
    From the statement that "the density was removed" I guess an argument could be made that the entire mass/lesion was removed. I have to admit I would query the physician as to whether or not the whole mass/lesion was removed and ask for a corrected OP note but that's just how I do it.
    If the whole thing was removed it would be 19125.
    I have the Ingenix General surgery coding companion and I love it! It goes into a more in depth description of procedures so that I can compare them to the OP notes to see if the surgery performed meets the criteria of the code I am looking at
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  6. #6
    Default
    Thanks guys!

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