Breast coding update - Understand surgical breast procedures to assign correct CPT codes

Hi to all… I thought it was fitting that I bring back an old article that I wrote in 2006, but updated with the new codes… A lot of good info here, and still as timely today, as it was then… Enjoy

Understand surgical breast procedures to assign correct CPT codes

Coders should understand medical terminology regarding surgical breast procedures to correctly bill the operative procedure that the physician performs. CPT has a complete section devoted to the breast. In this section, it is broken down into the following five core areas:

• Incision – Surgical opening made with an instrument such as a scalpel or knife -
• Excision – The surgical act of cutting out, cutting away or taking out
• Introduction – Directing or placing of a needle, catheter or other medical implement into the body
• Repair/reconstruction – To surgically correct a defect back to its original state
• Unlisted procedures – No current CPT code given to a specific procedure that the physician as documented.

Understand incision breast codes

Report the following codes for incision procedures:

• 19000—Puncture aspiration of cyst of breast –

Explanation: A direct access (through the skin) to a cyst or lump within the breast is performed with a needle or trocar, then the fluid or tissue is removed and sent to pathology for analysis. Some clinicians refer to this as a percutaneous breast aspiration. These are most often performed in the office setting.

• +19001—Add on code for each additional cyst (listed separately)

Explanation: A CPT code that is “added on” to the core code but cannot have a 51 modifier attached.

• 19020—Mastotomy w/exploration OR drainage of abscess deep –

Explanation: a surgical opening of the breast with a scalpel or knife so the physician can look around (or explore) the interior of the breast tissue. This code can also be used if the physician surgically opens the breast (incision) to drain a cyst or abscess. This procedure can be performed in the office, but many physicians prefer to do them in a surgical suite, or outpatient setting.

• 19030—Injection procedure for ductogram or galactogram

Explanation: A Physician or technician injects with a needle, contrast dye directly into the breast to image the breast ducts. These diagnostic tests are usually performed for a diagnosis of abnormal nipple discharge.

Understand excision breast codes

Report the following codes for excision procedures:

• 19100—Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)

Explanation: A biopsy the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion”. X-ray or ultrasound guidance is not used. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

• 19101—Biopsy of breast; open, incisional

Explanation: An incision is made in the breast near the site of the mass or lump. The mass or lump is identified and a small tissue specimen is removed. This specimen is examined immediately. If the mass or lump is benign, the wound is repaired with layered closure. If malignant, the incision may be closed pending a separate, more extensive surgical session.

• 19102—Biopsy of breast; percutaneous, needle core, using imaging guidance

Explanation: A biopsy of the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion”. X-ray or ultrasound guidance IS USED. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

• 19103—Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance

Explanation: A biopsy of the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion” that utilizes vacuum assistance, and rotates. X-ray, fluoroscopy or ultrasound guidance IS USED. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

Add on code :+ 19295—Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure)

Explanation: An actual metal clip or wire is placed within the breast, and used to delineate the area of the breast that the physician needs to biopsy or perform an open exploration.

• 19105—Ablation, cryosurgical, of fibroadenoma, including ultrasound guideance, EACH fibroadenoma

Explanation: The physician uses cryotherapy to obliterate a fibroadenoma of the breast. The patient's skin is cleansed and the ablation site is anesthetized. Ultrasound is used to locate the tumor. A cryoprobe is inserted through a small incision and placed within the fibroadenoma under ultrasound. The device initiates ice ball formation. The cryoprobe is warmed before removal from the breast. This code reports treatment of one fibroadenoma.

Radiology codes to consider with codes 19100–19103 include 76095, 76096, 76360, 76393 and 76942.

Understand FNAs

Fine needle aspiration (FNA) is a percutaneous procedure that uses a fine gauge needle (22 or 25 gauge) and a syringe to extract sample fluid from a cyst or to remove clusters of cells from a solid mass. FNA is an integral part of the diagnosis and treatment for many minor breast symptoms. Physicians use it as a tool for the diagnosis of cancerous cells within the breast.

When a physician finds a lump in the breast, he or she will send the patient to have a mammogram or ultrasound of the breast (specialized x-rays of the breasts). Depending on what the diagnostic mammogram/ultrasound reveals, the physician will determine the next course of treatment. Many times, that treatment includes a FNA in the office to determine whether the lump is solid or cystic (fluid-filled). If the FNA does not reveal any diagnostic information, the physician may consider a breast biopsy.

FNA, incisional breast procedure codes, and excisional breast procedure codes are billable for both male and female patients are not age exclusive. However, some local insurance carriers may render a “gender” denial because they view these codes are female-only. However, in men, breast lumps/cancers account for fewer than 1% of all breast malignancies reported, and 80% of all breast lumps found are benign—not malignant—according to the Y-ME National Breast Cancer Organization.^©

Report the following codes to indicate a fine-needle aspiration:

• 10021—Fine needle aspiration; without imaging guidance
• 10022—Fine needle aspiration; with imaging guidance

Explanation: Fine needle aspiration (FNA) is a percutaneous procedure that uses a fine gauge needle (22 or 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. First, the skin is cleansed. If a lump can be felt, the radiologist or surgeon guides a needle into the area by palpating the lump. If the lump is non-palpable, the FNA procedure is performed under image guidance using fluoroscopy, ultrasound, or computed tomography (CT), with the patient positioned according to the area of concern. In fluoroscopic guidance, intermittent fluoroscopy guides the advancement of the needle. Ultrasonography-guided aspiration biopsy involves inserting an aspiration catheter needle device through the accessory channel port of the echoendoscope; the needle is placed into the area to be sampled under endoscopic ultrasonographic guidance. After the needle is placed into the region of the lesion, a vacuum is created and multiple in and out needle motions are performed. Several needle insertions are usually required to ensure that an adequate tissue sample is taken. CT image guidance allows computer-assisted targeting of the area to be sampled. At the completion of the procedure, the needle is withdrawn and a small bandage is placed over the area. Report 10021 if fine needle aspiration is performed without imaging guidance. Report 10022 if imaging guidance is used to assist in locating the lump.