Breast Surgery Coding 2010

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Navigant Consulting, Inc.
Breast Surgery Coding
for Hospital Outpatients and Physicians
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Your Speakers . . . Both speakers are based out of the NCI Baltimore office and work
primarily with hospital clients in the state of Maryland to provide consulting services on
outpatient coding and documentation improvement, billing compliance and middle revenue
cycle management.
Caroline “Rader” Znaniec, Associate Director caroline.rader@navigantconsulting.com
Ms. Rader has worked in healthcare for 15 years in such positions as Corporate Compliance
Officer, Auditor and Operations Manager. She is the designated service line leader within
NCI’s Healthcare Practice for CDM and Charge Integrity Services, including NCI’s latest
offering – Outpatient CDI. She has been an author and is a speaker for the Health Care
Compliance Association, a national and state (Maryland and Florida) level speaker for the
American Health Information Management Association, a speaker for various New York
State Health Care Financial Management Association Chapters, and the Maryland Health
Care Financial Management Association.
Nikisha Small, Managing Consultant nsmall@navigantconsulting.com
Ms. Small has extensive experience in professional and facility coding, revenue cycle
operations, denials management and practice management. Prior to joining NCI, Ms. Small
worked in Health Information Management, Physician Education, Compliance, and Coding
and Reimbursement with two of the nation’s leading academic facilities.

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Overview
Section 1
Overview
» Many men and women who are diagnosed with breast cancer, along with
those with other breast disease processes, can be effectively treated now
in an outpatient setting, although some procedures also may be provided
on an inpatient bases.
» Understanding the differences between the various diagnostic and
treatment options available is an integral skill for any coder.
» Common errors when reviewing coding of breast surgery procedures
› Incomplete capture of diagnoses
› Bundling/Unbundling of procedures
› Coding inaccuracies (e.g. biopsy type)
› Lack/Misuse of modifiers
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Diagnosis Coding
Section 2

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Diagnosis Coding
» When assigning diagnosis codes for a patient with a breast disease carefully
review all information available
› History and Physical (H&P),
› Procedure Report,
› Pathology or Cytology Report (if applicable), and
› Any other pertinent documentation in the medical record
» Common Diagnosis Categories
Benign 610 and 611, Disorder of Breast
Male or Female
Malignancy 174, Female or 175, Male
172 or 173 if skin only
Cancer In Situ 233
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CPT Procedure Coding
Section 3
» Modifier Use
› Modifiers should be assigned to all breast procedure CPT codes to
ensure appropriate specificity;
‒ RT (right side)
‒ LT (left side)
‒ 50 (bilateral procedure)
› Any and all CCI edits should be considered
› When appropriate apply modifier -59 (distinct procedural service)
› More information
‒ http://campus.ahima.org/audio/2008/RB041708.pdf
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» Breast Fine Needle Aspirations (FNA)
› Less invasive option for patient when suspicious lesion is detected
‒ Commonly performed in office or clinic setting
‒ A fine needle is inserted through the skin of the breast into the suspicious
area and fluid or clusters of cells are removed for cytologic analysis
‒ May be further recommended to have an incisional or excisional biopsy
procedure
› FNA services are reported with one of two codes, differentiated by
whether imaging guidance was used to accomplish the procedure
‒ 10021 (Fine needle aspiration; without imaging guidance)
‒ 10022 (Fine needle aspiration; with imaging guidance)
◦ Guidance may include CT, US, Fluoroscopy, MRI
◦ Guidance use must be clearly documented
◦ Imaging guidance CPTs are reported in addition
◦ Metallic clip placement (CPT 19295) can be added in
addition
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2010
» Breast Puncture Aspiration
› More invasive option than FNA for patient that has a fluid filled cyst
‒ Commonly performed in office or clinic setting
‒ This procedure involves the physician inserting a syringe needle through the
skin of the breast into the cyst and fluid is evacuated, thus reducing the size
of the cyst.
› Puncture aspirations are reported with one or two codes
‒ 19000 (Puncture aspiration of cyst of breast)
‒ 19001+ (each additional cyst)
‒ Imaging is identified by use of a separate CPT describing the modality
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» Breast Biopsies
› Includes
‒ Needle Core
‒ Stereotactic
‒ Incisional
‒ Excisional
› Each has their own coding guidelines
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» Needle Core Breast Biopsies
› A large gauge needle is inserted through the skin of the breast and into
the suspicious tissue
› The needle is removed along with a core of breast tissue
› Coding is dependent on the use of imaging guidance
‒ 19100 (Biopsy of breast; percutaneous, needle core, not using imaging
guidance)
‒ 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance)
◦ Imaging guidance is captured in addition even though the description of
the surgical procedure indicates “using imaging guidance”
› Each insertion of the needle can result in multiple core samples,
commonly up to 5 from a single lesion
‒ The CPTs are reported per lesion sampled
› Imaging of the specimen should also be identified
‒ 76098 (Radiological examination, surgical specimen)
‒ Performed to provide the surgeon with immediate results
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» Stereotactic Breast Biopsies
› An automated vacuum assisted or rotating biopsy device is inserted
through the skin into the suspicious breast tissue and a core of suspect
tissue is removed for biopsy
› The needle is removed along with a core of breast tissue
› A single CPT code describes the procedure
‒ 19103 (Biopsy of breast; percutaneous, automated vacuum assisted or rotating
biopsy device, using imaging guidance)
◦ Imaging guidance is captured in addition even though the description of
the surgical procedure indicates “using imaging guidance”
› A single insertion of the needle/device can result in multiple samples
‒ Its not expected that multiple insertions would occur
› Imaging of the speciment should also be identified (CPT 76098)
› Keywords to identify a stereotactic breast biopsy by device utilized
Mammotome Suros
Encor ABBI
MIBB (Minimally Invasive Breast Biopsy)
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» Incisional Breast Biopsies
› Incision is made into the breast near the site of the suspicious mass and
a sample is removed
› Code when the incision is closed and no other procedure performed
‒ 19101 (Biopsy of breast; open, incisional)
› If another service (more extensive) is performed immediately the initial
biopsy is not coded
› Imaging guidance is identified by use of a separate CPT describing the
modality
› Imaging of the speciment should also be identified (CPT 76098)
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» Excisional Breast Biopsies
› The entire mass is excised for biopsy
› May include localization before or during excision procedure
‒ A needle placed into the breast lesion preoperatively to assist in exact
identification of the affected suspicious tissue
‒ A separate code for the placement of the localization device should be
assigned separately to the excision procedure
◦ 19120 (Preoperative placement of needle localization wire, breast)
◦ 19121+ (each additional lesion)
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HOSPITAL CDM TIP
If the preoperative placement is performed outside of the surgical procedure
this should be noted. This can occur in radiology and not in the operating
room. In this case, hospitals should understand who/where the preoperative
placement will be captured, documented and coded.
» Excisional Breast Biopsies (continued)
› CPT coding should reflect an “excision” and not a “biopsy”
‒ Actual codes are dependent on use of localization device
◦ No Device
▫ 19120 (Excision of cyst, fibroadenoma, or other benign or malignant
tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion
{except 19300}, open, male or female, 1 or more lesions)
▫ Code should only be reported once, regardless of number of lesions
excised through the same incision
▫ If multiple separate incisions, report more than once with modifier
◦ Device
▫ 19125 (Excision of breast lesion identified by preoperative placement
of radiological marker, open; single lesion)
▫ 19126+ (each additional lesion separately identified by a preoperative
radiological marker)
▫ These codes include the preoperative placement of a needle
localization device (e.g. wire or clip)
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» Mastectomy
› Broad term to describe any therapeutic excisions of breast tissue
› Mastectomy CPT procedures are unilateral by code definition
‒ Append modifier -50 for bilateral procedures
› There are different techniques and nomenclature that will determine the
appropriate procedure coding
‒ Partial
◦ Lumpectomy,
◦ Quadrantectomy, or
◦ Segmental mastectomy
‒ Simple and “Modified”
‒ Subcutaneous
‒ Radical
‒ Radical and “Modified”
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» Partial Mastectomy
› The lesion or mass is excised from the breast, along with a margin or rim
of healthy tissue
‒ “attention to adequate surgical margins”
› 19301 (Mastectomy, partial {e.g. lumpectomy, tylectomy,
quadrantectomy, segmentectomy)
› 19302 (Mastectomy, with axillary lymphadenectomy)
‒ Assign if the procedure includes the excision of axillary lymph nodes
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» Simple “Modified” Mastectomy
› Includes the removal of all breast tissue, along with portion of skin
and nipple through elliptical incision
› 19303 (Mastectomy, simple, complete)
» Subcutaneous Mastectomy
› Similar to simple with the exception of the extent of the excision
‒ Simple
◦ The breast is dissected from the pectoral fascia and from the skin
‒ Subcutaneous
◦ The breast tissue is removed, but the skin and pectoral fascia remain
› 19304 (Mastectomy, subcutaneous)
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» Radical Mastectomy
› Most extensive of mastecomy procedures
‒ Involves dissection of breast, overlying skin, pectoralis major and minor
musles and the axillary lymph nodes
‒ All are removed as a single specimen
› Coding dependent on excision of axillary and/or internal mammary
lymph nodes
‒ 19305 (Mastectomy, radical, including pectoral muscles, axillary lymph
nodes)
◦ Axillary lymph nodes only
‒ 19306 (Mastectomy, radical, including pectoral muscles, axillary and internal
mammary lymph nodes {Urban type operation)
◦ Axillary and internal mammary lymph nodes
› A “modified” mastectomy spares the pectoralis muscles
‒ 19307 (Mastectomy, modified radical, including axillary lymph nodes, with or
without pectoralis minor muscle, but excluding pectoralis major muscle)
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» Breast Prosthesis
› Breast prosthesis insertion is often performed at the same surgical
episode as the mastectomy, or can be inserted later as a separate
procedure
› Coding differs on timing of procedure
‒ 19340 (Immediate insertion of breast prosthesis following mastopexy,
mastectomy or in reconstruction)
◦ Performed during same surgical session
‒ 19342 (Delayed insertion of breast prosthesis following mastopexy,
◦ Performed at a later date
› Can also occur when the patient has undergone mastopexy or another
reconstructive breast procedure
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» Breast Reconstruction
› There are various approaches to breast reconstruction
‒ Latissimus Dorsi Flap
‒ Transverse Rectus Abdominis Myocutaneous Flap (TRAM)
‒ Free Flap
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» Latissimus Dorsi Flap
› The physician dissects a portion of the latissimus muscle from the
patient’s back; the muscle-skin flap remains attached to a main artery
and is then rotated to the front of the chest through a tunnel under the
patient’s armpit so that it extends through to the mastectomy incision
› Flap is attached to the chest wall and adjacent muscles for the most
aesthetic appearance
› 19361 (Breast reconstruction with latissimus dorsi flap, without
prosthetic implant)
‒ Procedure only
› 19340 (Immediate insertion of breast prosthesis following mastopexy,
‒ Add on if implant also inserted
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» Transverse Rectus Abdominis Myocutaneous Flap (TRAM) Breast
Reconstruction
› A muscle/skin flap transfer in which the rectus abdominis muscle is
divided, but kept attached to its blood supply. It is passed through a
connecting tunnel between the elevated chest skin and the inferiorly
positioned flap. The muscle is contoured to make a breast mound.
› 19367 (Breast reconstruction with transverse recturs abdominis
myocutaneous flap (TRAM), single pedicle, including closure of donor
site)
‒ One pedicle flap
› 19368 (with microvascular anastomosis (supercharging)
‒ If additional microvascular anastomosis for connecting blood vessels is
provided
› 19369 (Breast reconstruction with transverse rectus abdominis
myocutaneous flap (TRAM), double pedicle, including closure of donor
site)
‒ If muscle/skin complex having two pedicles or both sides of the rectus
abdominis are elevated; bilateral or hemiflaps
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» Free Flap Breast Construction
› Breast reconstruction with the use of a free flap involves excision of a
completely free flap of skin, fat and muscle from another site on the
patient, typically the thigh or buttocks.
› The excision includes careful dissection of vascular channels, which are
anastomosed or attached to the mastectomy site via a microvascular
technique to ensure a viable blood supply
› 19364 (Breast reconstruction with free flap)
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» Post Breast Reconstruction
› After reconstructive breast surgery procedures, it may be necessary to
return for further surgery related to the previous procedure, particularly
if an implant is involved.
‒ Removal of Intact Mammary Implant
‒ Removal of Mammary Implant Material
‒ Periprosthetic Breast Capsulotomy
‒ Periprosthetic Breast Capsulectomy
‒ Breast Reconstruction Revision
‒ Chest Wall Tumor Procedures
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» Removal of Mammary Implant Material
› A breast implant is not intact and has leaked, or the material has
otherwise migrated from its original location
› May require removal by a piecemeal approach.
› An incision is made and the implant material is carefully dissected
› 19330 (Removal of mammary implant material)
‒ Removal only
› 19340 (Immediate insertion of breast prosthesis following mastopexy,
‒ Add on to indicate replacement
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» Periprosthetic Breast Capsulotomy
› After breast implantation, an extensive capsule may form around the
implant,
› An incision is made around the capsule’s circumference, with no
removal of tissue
› 19370 (Open periprosthetic capsulectomy, breast)
» Periprosthetic Breast Capsulectomy
› The fibrous breast implant capsule may progress to a point in which the
decision is made to remove it, along with the scarred tissue
› A circumferential incision is made around the implant, the contracted
capsule is excised from the breast tissue and the prosthesis is removed.
› 19371 (Periprosthetic capsulectomy, breast)
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» Breast Reconstruction Revision
› A reconstructed breast may require some revision, most commonly for
asymmetry.
› An incision is made and the tissues may be rearranged or secured with
sutures to revise the shape of the breast
› The existing implant may be replaced and excess skin or tissue may be
removed
› 19380 (Revision of reconstructed breast)
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Imaging Guidance
Section 4
Imaging Guidance
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» Imaging Guidance
› Image guidance refers to the use of an imaging modality to identify the
exact location of the area to be treated or sampled
› Imaging is also used to ensure that the needle is placed in the correct
location to obtain the biopsy
› For most drainage, aspiration, and biopsy procedures. imaging is not
included in the base code and should be reported separately
› The modality chosen depends on the site and characteristics of the fluid
collection or lesion
› Documentation of needle or catheter tip location is a required (American
College of Radiology) ACR standard
› It is found that some modalities are not mentioned in the AMA cross
references, but may be utilized, and these do not present a NCCI edit
‒ Fluoroscopy and CT guidance are commonly omitted
Imaging Guidance
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MOST COMMON IMAGE GUIDANCE PROCEDURES

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Imaging Guidance
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» Imaging Guidance
› Dependent on the clinical scenario, more than one modality may be
reported when guidance is accompanied by additional imaging
‒ Must be a documented separately and represent different modalities
◦ Example:
▫ Ultrasound guided breast biopsy
▫ Mammographic post biopsy verification
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Frequently Asked Questions
Section 5
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Q1. Are breast biopsy procedures reported per lesion or sample? What about
the imaging guidance?
A1. When performing breast biopsies, if multiple breast biopsies are performed,
the biopsy procedure code and radiological supervision and interpretation
(imaging) codes are submitted per lesion and NOT per sample.
Q2. Is it appropriate to report a diagnostic magnetic resonance imaging (MRI)
study code and an MRI guidance code when MRI guidance is performed
for breast biopsy?
A2. Yes, if a diagnostic MRI breast study is performed on the same day as the
MRI-guided breast biopsy, it is appropriate to report the diagnostic MRI code
and the MRI guidance code, as well as the appropriate surgical code for the
breast biopsy. However, if a diagnostic MRI study has been performed on the
same day prior to the breast biopsy and MRI sequences are performed for
localization purposes only, these sequences are part of the guidance and
should not be reported separately.

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Q3.How are multiple ultrasound-guided breast cyst aspirations of the same
breast reported?
A3. The number of breast cyst aspirations reported is based on the number of
breast cyst aspirations performed. For example, if three breast cysts are
aspirated under ultrasound guidance, it is appropriate to report 19000 once,
for the first cyst aspirated, 19001 twice, for the second and third cysts
aspirated, and 76942 three times, for the ultrasound guidance. The
ultrasound image guidance is reported per cyst aspirated.
Q4. Can you report a breast biopsy code multiple times when multiple
samples are taken from the same lesion?
A4. No, if multiple samples are taken from the same lesion, the biopsy code
should be reported only once. However, when separate lesions are sampled
during the same session, it is appropriate to report the biopsy code multiple
times based on the number of separate lesions sampled.
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Q5. How is the placement of a metallic localization clip reported when not
performed in conjunction with a breast biopsy or aspiration procedure?
A5. The placement of a metallic localization clip should be reported with the
unlisted breast procedure code 19499. CPT code +19295 (Imaged guided
placement, metallic localization clip, percutaneous, during breast biopsy or
aspiration (list separate in addition to code for primary procedure) cannot be
reported because it is an add-on code and it is specific to the placement of a
clip during a biopsy or aspiration procedure.
Q6. Our physicians have noted the use of the Mammotome biopsy device, but
have described a core biopsy procedure. How should this be coded?
A6. The Mammotome biopsy device is a vacuum assisted device. Core samples
are obtained, but by AMA CPT definition the appropriate CPT would be
19103, “Biopsy of breast; percutaneous, automated vacuum assisted or
rotating biopsy device, using imaging guidance”. The imaging guidance
would also be reported, dependent on modality utilized.
Section 6
» A breast implant may require removal for a number of reasons, including
infection, displacement, excessive capsule formation or pain. When the
implant is considered intact, has not ruptured and can be removed in one
piece, assign;
‒ CPT Code 19328 and add code 19430 if another implant is placed at
the same surgical episode
‒ ICD-9-CM code 85.94 should be assigned for this procedure.
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