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Evaluation of surgical margins

Hi,
I am new to pathology coding and am trying to determine what constitutes evaluation of surgical margins in a pathology report for a breast excision of lesion, requiring microscopic evaluation of surgical margins. In the reports I have seen, the pathologist are only documenting (along with the breast biopsy), "The medial margin is inked blue", "The anterior margin is inked yellow". Nothing further, nor is there anything noted in the diagnosis regarding the margins. Is the fact that they simply mention the margins in the report enough to code for 88307?

Any guidance is appreciated!

Thanks!
Kathleen

Medical Billing and Coding Forum

Help with Re-excision of margins for breast cancer

I may be over thinking this due to it being late in the day, so I thought I would ask for help

I have a patient in office procedure Margin Re-excision as follows…..

Indication: The patient has a recurrent breast cancer of the skin and subcutaneous tissue of the left breast which wider excision is recommended.

After obtaining informed consent, the skin of the left breast at the 9 o’clock aspect was prepped with Betadine. I then infiltrated 10 cc’s of lidocaine.
I made a 4.0 cm X 2.0 cm elliptical incision around her previous biopsy site and went deep down into the fatty tissue. The lesion was removed. The margins are labeled. The wound was closed in 3 layers.
The deep layer with 3.0 vicryl, the intermediate layer with 3.0 vicryl and the skin with 4.0 monocryl in a running subcuticular fashion.

Should I code this as 19120 due to the depth, or 11606, 12032 or something completely different?

HELP,

Thanks,

Michelle

Medical Billing and Coding Forum

Separate surgical margins with breast case

Excision of breast mass w/ margins is performed and the path report returns with Ductal Carcinoma in Situ (88307). Along with the breast specimen are 6 separately submitted margins. Each margin is described as "new superior margin stitch true margin" or another location such as new medial, new posterior and so on. Each specimen states suture present and inked with black. The final diagnosis on each states "New ______ margin biopsy: Benign Breast tissue, No Tumor Seen. The pathologist is submitting these margins as Breast specimen, excision of lesion w/ indicated margins and billing a 88307 for each. What would be the correct code to report 88305 or 88307? No documentation stating they are microscopically examined. Other than the actual breast specimen, the others are the surgical margins of the breast excision. I am thinking 88305?
Any advice appreciated.

Medical Billing and Coding Forum

Mastectomy or Excision? Consider the Margins

When deciding between 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 and 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy, search the documentation to determine whether a margin of health tissue was removed, […]
AAPC Blog

Mastectomy or Excision? Consider the Margins

When deciding between 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 and 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy, search the documentation to determine whether a margin of health tissue was removed, […]
AAPC Blog