Frequently asked questions about CPT coding for breast surgery: An update

The American College of Surgeons (ACS) receives many questions at the ACS General Surgery Coding Workshops. The September 2014 Bulletin included an article with frequently asked questions about American Medical Association (AMA) Current Procedural Terminology (CPT)* coding for breast procedures. This article provides additional examples of correct coding for breast procedures.

Which CPT code is reported for a Tru-Cut biopsy of the breast when ultrasound is not used for guidance?

Biopsy tissue can be obtained through fine needle aspiration biopsy, core needle biopsy, or through an open surgical procedure (incisional or excisional biopsy). Tru-Cut soft-tissue biopsy needles are considered core needles. So the correct code to report for this procedure is 19100, Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure). Best practice is to perform a needle biopsy before surgical removal for breast lesions that are not clearly benign based on clinical or radiographic criteria.

During a partial mastectomy (lumpectomy), the surgeon places a BioZorb marker to identify the site for radiation treatment at a later time. What code is reported for placement of this marker?

Intraoperative placement of clips (or markers) at the time of open excision of a breast lesion (19125–19126) or at the time of a mastectomy procedure (19301–19307) is inherent to the procedure and not separately reportable. If the BioZorb device is placed only to mark the surgical site for later identification, no additional code should be used.

While the surgeon was performing a mastotomy on a patient for a breast abscess, the surgeon noticed abnormal tissue and took a biopsy of the tissue for pathology review. Can we report both procedures?

A biopsy of a mass or lesion is not inherent to a mastotomy for a breast abscess. Report both code 19020, Mastotomy with exploration or drainage of abscess, deep, and code 19101, Biopsy of breast; open, incisional. Depending on payor preference, modifier 51, Multiple procedures, would be appended to 19101.

The surgeon percutaneously placed a lesion marker in the breast using ultrasound guidance and then performed an open excisional biopsy. How is this procedure reported?

Report both code 19285, Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance, and code 19125, Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion. Depending on payor preference, modifier 51 would be appended to 19285.

What codes are reported for a partial mastectomy (lumpectomy) with biopsy of sentinel axillary nodes using both blue dye and intraoperative ultrasound to identify the sentinel nodes?

Report the following codes: 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); 38525, Biopsy or excision of lymph node(s); open, deep axillary node(s); +38900, Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure); and 76998-26, Ultrasonic guidance, intraoperative.

Intraoperative ultrasound may be performed to locate lymph nodes where a marker was placed at the time of a previous biopsy or when the lymph node is scarred after chemotherapy and not receiving afferent flow from the remaining lymphatics; that is to say, that neither blue dye nor radioactivity can be used to identify the target node. However, code 76998 may only be reported if permanent images in either an analog or digital manner are recorded and a report is entered into the medical record. Imaging codes have a professional and technical component. Modifier 26, Professional component, is appended to the imaging code when the services are performed in a facility setting. If an imaging service is performed in an office setting, then no modifier is appended because both the professional and technical components apply.

The surgeon performed a partial mastectomy on one breast, but actually made two separate smaller incisions to remove two separate lesions (lumpectomy) from different non-contiguous areas of the breast. Can the surgeon report 19301 twice using modifier 59, Distinct procedural services?

Multiple lesions in separate distinct locations of the same breast are uncommon. When the potentially malignant tissue is not connected and tissue is removed from different, separate incisions, then code 19301 should be reported twice, with modifier 59 appended to one instance (19301, 19301-59). Documentation of each distinct procedure is important.

What codes do I report if a radiotracer and blue dye were injected in the breast before a complete mastectomy and neither agent migrated from the injection site, so that I was unable to identify a sentinel lymph node?

Report code 19303, Mastectomy, simple, complete, for the mastectomy. Sentinel node mapping is reported with code 38900, but it is an add-on code that may only be reported with select codes (Report 38900 in conjunction with 19302, 19307, 38500, 38510, 38520, 38525, 38530, 38542, 38740, 38745). If an axillary lymph node biopsy was attempted but not performed, report 38525 and append modifier 53, Discontinued procedure, and report add-on code 38900 for the sentinel node mapping. If the payor prohibits reporting 38525-53, then the code for sentinel lymph node mapping (38900) also may not be reported because it is not an add-on code to 19303.

What is the correct code to report for performing a partial mastectomy on a male patient who had both an unspecified mass and gynecomastia if the intraoperative pathology for the mass was negative?

Report code 19300, Mastectomy for gynecomastia, for this procedure. Removal of the mass was part of the mastectomy procedure. Remember, however, that in men, as in women, it is best practice to evaluate unspecified breast lesions with needle biopsy before a surgical biopsy.

A patient with bilateral breast implants develops breast cancer in the left breast and undergoes a modified radical mastectomy of the left breast with removal of the bilateral implants. How do we report this procedure?

The Medicare National Correct Coding Initiative (NCCI) edits indicate that codes 19307, Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle, and 19328, Removal of intact mammary implant, are “mutually exclusive,” but allow a modifier to bypass the payment edit if the procedures are performed at different anatomic sites or on different organs. In this instance, removal of the implant in the left breast would be included with radical mastectomy of the left breast. However, removal of the implant in the right breast is a distinct operation. Because there is a code pair edit for 19307 and 19328, modifier 59, Distinct procedural service, is used instead of modifier 51, Multiple procedures. The correct codes and modifiers to report for these procedures are: 19307-LT, 19328-59-RT. NCCI edits are available online.

I performed a mastectomy on a woman and one week later placed a central venous line with port for chemotherapy. What code should be reported for the catheter and port, and does a modifier need to be appended since I am still in the 90-day global period for the mastectomy?

The catheter and port placement is reported with code 36561, Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older. Append modifier 79, Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period, to code 36561. It would be inappropriate to append modifier 58, Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period, to code 36561 because the port is in a different anatomic location and is not a staged or more extensive procedure to the mastectomy.

Note

Accurate coding is the responsibility of the provider. This column is intended only to serve as a resource to assist in the billing process.


*All specific references to CPT codes and descriptions are © 2017 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Barney L, Savarise M, Whitacre E. Coding and practice management corner: Frequently asked questions about coding for breast surgery. Available at: bulletin.facs.org/2014/09/frequently-asked-questions-about-coding-for-breast-surgery/. Accessed on July 19, 2018.

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