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Excisional biopsy vs biopsy

  1. #1
    Default Excisional biopsy vs biopsy
    Medical Coding Books
    I always thought if doctor states excisional biopsy he/she is taking the entire lesion/mass out. Another coder disagrees with me stating a biopsy is a biopsy and itit states biosy could it as a biopsy . Not sure if I agree. Here is an example
    I say this is 19120 while other coder says this is 19101- biopsy

    PREOPERATIVE DIAGNOSIS: Right breast mass.

    POSTOPERATIVE DIAGNOSIS: Right breast mass.

    PROCEDURE PERFORMED: Excisional biopsy of right breast mass.

    ANESTHESIA: General.


    CLINICAL HISTORY: patient with an area on upper aspect of areola that has repeatedly become infected and has recurred despite the incision and drainage.

    PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on operating room table in supine position. The right breast was prepped and draped in sterile fashion. An elliptical incision was made on the upper aspect of the right areola. Sharp dissection was used to dissect through the subcutaneous tissue to excise the mass, which was immediately beneath the skin. The implant was not visualized during the procedure. There was no purulence. The mass was completely resected with grossly negative margins. The wound was irrigated first with Betadine and then with normal saline. It was inspected and found to be hemostatic. The skin was closed with interrupted 3-0 nylon sutures. A sterile dressing was applied. The patient tolerated the procedure well.

  2. #2
    Salt Lake City
    Excision just means there was an excision made vs needle biopsy or punch biopsy for example.
    Jenifer McPolin CPC, CPMA, RCC

  3. #3
    so would 19120 would be correct ?

  4. #4
    Columbia, MO
    The report states the entire mas was removed so this is not a biopsy. A biopsy is a piece of the mass removed, so if it had not all been removed for some reason such as due to the size or location and a piece was removed for path then that is a biopsy but when the entire mass is removed as in this report then it is an excision so I agree with you.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    thank you ,

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