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For coders working with surgeons who specialize in surgical oncology, a common coding scenario you may need to decipher is whether to code excision of a breast mass (CPT 19120) or a partial mastectomy (CPT 19301).

Before we compare some examples and determine which code would be appropriate, let’s start by looking at the description of these two codes to compare them and understand why coders sometimes struggle to choose between these codes:

CPT 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

CPT 19301: Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

The term “excision” that we see in the description for CPT 19120 means “to remove.” The excision described in this code is removal of some of the breast tissue due to an area of disease such as a mass/lesion, cyst, tumor, or benign or malignant neoplasm. As we move forward with the rest of the article, we will refer to all of these abnormalities as a “mass” to keep things simple, but there are some differences in what these terms mean clinically so you can check out the definition of each by hovering over the terms in the previous sentence if you like. The term “mastectomy” that we see in CPT 19301 also means “to remove” and specifically “to remove breast tissue” (mast- or masto- means “breast” and -ectomy means “to excise”). We also see the term “partial” following the word mastectomy clarifying that, while different terms may be used to describe the procedure represented by CPT 19301, including lumpectomy, quadrantectomy, etc., all of these procedure include removal of “part” of the breast rather than removal of the entire breast. As you can see, on the surface, both codes include excision of part of the breast. So how do you distinguish between the two codes and know which CPT to pick?

For CPT 19120, the physician is excising the breast mass alone. He/she isn’t overly concerned about whether they excised the “entire mass” or if they left a small part of the mass behind. The goal is just to “roughly remove” the mass. This procedure is usually performed in cases where the surgeon suspects that the mass is non-cancerous such as a cyst or fibroadenoma. This procedure may also be performed though when the surgeon is not sure if the tissue is cancerous or non-cancerous and wants to be conservative and not remove too much of the breast tissue until he/she has the final pathology report back and knows if additional excision is warranted. CPT 19120 is reported only once per breast whether one or more lesions are removed.

On the other hand, the key you are looking for in the operative report to assign CPT 19301 for a partial mastectomy is “attention to margins.” In CPT 19301, the surgeon must ensure that he/she has “negative margins” which involves removing the mass along with a rim of normal breast tissue around the mass to make sure no diseased tissue is left behind. That rim of normal tissue removed around the mass is called a margin (meaning “the edge”) because that normal tissue removed is around the outside edge of the mass in the final specimen removed. While a partial mastectomy is not always performed to treat cancer, breast cancer is one of the most common indications for a partial mastectomy since it is particularly important with cancer to ensure that you leave no diseased tissue behind and that you have “negative margins.”

Coding tip: Not every reference to the word “margin” in an operative report for excision of a breast mass refers to ensuring that the surgeon has “negative margins” as described above. Another reference you may see to the term “margins” is when the surgeon is marking a specimen for the pathologist. He/she may say that they “oriented the specimen” and “labeled the margins” (e.g., “I then used two sutures to mark the superior, inferior, and lateral margins”). This reference to the word “margin” does not automatically make this procedure a lumpectomy because it does not refer to the intent to obtain negative margins by taking a rim of normal tissue around the breast mass to ensure no diseased tissue remains after surgery. It is not uncommon for surgeons to mark and label the “margins” (or “edges” of the specimen) for a pathologist even in a case where a breast mass was excised without particular attention to margins. The surgeon marks the edges of the specimen in this way because he/she wants the pathologist to understand how that tissue was originally positioned in the patient’s body. This information is particularly useful should the pathology come back positive for cancer because it allows the surgeon and the pathologist to speak the same language in terms of identifying which margin/edge may still have cancer present and require further excision. In this example where the surgeon is simply labeling the margins/edges for the pathologist without taking additional tissue around the mass to ensure negative margins, you would code CPT 19120 not 19301.

Let’s try out what we’ve learned with a couple of examples:

Example #1: A 64 year old patient presents with a firm mass in the upper outer quadrant of the right breast. The mass by clinical exam and mammography is highly suspicious for cancer (mammogram is a BIRADS 4). Recommendation is for excision for final diagnosis and to determine if additional treatment is warranted.

After sterile prep and drape, a curvilinear incision was made in the vicinity of the mass in the upper outer quadrant of the right breast. Dissection was carried around the mass circumferentially ensuring to take additional tissue on all sides of the mass to ensure adequate resection. Frozen pathology was positive for invasive adenocarcinoma. The pathologist also relayed that the superior margin had cancer extending to 1 mm from the inked edge so an additional cut of tissue was taken from the breast superiorly. The incision was then closed in layers.

This concludes our procedure. Patient to follow up in the office in 7-10 days for suture removal and to receive final pathology results and discuss treatment options.

Coding for Example #1: The bolded portions of the note above are clues to selecting our CPT code. We first see the surgeon “circumferentially dissecting” (or cutting all the way around) the mass and that he “is ensuring to take additional tissue on all sides to ensure adequate resection.” This statement qualifies as attention to margins because he is taking additional normal tissue all the way around the mass and being careful to ensure he has complete resection and doesn’t leave any diseased tissue behind. While some surgeons will refer to taking “margins of tissue” around the mass others will describe something that means the same thing without ever using the word margin (this is a good example of a statement that does not use the word margin but does describe attention to margins). We then see the pathologist confirms this is cancer, and he’s a bit concerned that the superior (upper) part of the specimen may still have cancer too near the margin/edge on that side so the surgeon takes additional tissue on the superior edge of the cavity he’s created in the breast. This sentence further confirms the surgeon’s “attention to margins” but even without this sentence, the first statement about taking additional tissue to ensure adequate resection would support attention to margins. Based on these details, this example would be coded with CPT 19301.  I would also add modifier RT since this procedure occurs on the right breast, and CPT 19301 allows modifier 50 for a bilateral procedure on both sides per the Medicare Physician Fee Schedule (MPFS). When a code allows modifier 50, the laterality modifiers RT or LT would apply to that same code when the procedure described by the code is performed only on one side.

Example #2: A 27-year-old patient presents with a lump in the left lower quadrant of the left breast. Clinical presentation and ultrasound findings are consistent with a benign fibroadenoma. Patient was offered options of surgical excision vs. close interval monitoring with repeat ultrasounds and mammography. Patient has elected to have the area removed.

After sterile prep and drape, the area of concern in the left lower quadrant of the left breast was identified, and we made a circumferential incision around the palpable mass. The mass was excised and placed in formalin for transport to pathology. We carefully inspected our cavity and ensured hemostasis. The incision was closed in layers with sutures.

The patient will follow up in 7-10 days for a wound check and pathology results.

Coding for Example #2: The bold portions of the note above are clues to selecting our CPT code. This case starts similar to example #1 with a circumferential incision (an incision all the way around) the mass. From there though, we see that the surgeon excises the mass alone and sends it off for pathology which is typical anytime tissue is removed from the body. We see no excision of any additional tissue around the mass and no mention of the intent to ensure that no diseased tissue is left behind (no “attention to margins”). The goal is simply to remove the mass which is expected to be a benign area. This documentation supports CPT 19120. I would also add modifier LT since the procedure occurs on the left breast, and this CPT also permits modifiers 50/LT/RT per the MPFS.

Continuing our series on some notable changes to CPT this year, codes for biopsies of skin lesions have been expanded.

Prior to this year, we had two codes to represent a biopsy of a skin lesion: CPT 11100 for the first lesion biopsied and CPT 11101 for each additional lesion biopsied. When these codes were created many years ago, they were sufficient to accurately report the types of biopsies being performed at the time. As time has gone on, though, many different techniques for biopsying a lesion have emerged, and the work that goes into performing a biopsy can vary based on the technique used. For that reason, the AMA revised the skin lesion biopsy codes this year to more accurately describe the “method” for obtaining the biopsy.

Below are the new codes and their definitions. Notice that we have a primary or parent code for the first lesion biopsied for each method of biopsy and an add on code for each additional/separate lesion:

• CPT 11102: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); single lesion

• + CPT 11103: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); each separate/additional lesion (list separately in addition to code for primary procedure)

• CPT 11104: Punch biopsy of skin (includes simple closure when performed); single lesion

• +CPT 11105:  Punch biopsy of skin (includes simple closure when performed); each separate/additional lesion (list separately in addition to code for primary procedure)

• CPT 11106: Incisional biopsy of skin
  (e.g., wedge) (including simple closure, when performed); single lesion

• +CPT 11107: Incisional biopsy of skin
  (e.g., wedge) (including simple closure, when performed); each separate/additional lesion (list separately in addition to code for primary procedure)

To understand how to code with the expanded options available for this procedure, it is necessary to first understand some key definitions and rules for their use.

Key Definitions:

• The skin is made up of two layers of tissue. The epidermis is the outermost layer of the skin and provides protection against germs and a water-proof barrier to protect our inside organs. The dermis is the inner layer of the skin which lies between the epidermis and the subcutaneous tissue and provides toughness and flexibility for the skin.
• These different methods of biopsies may take a “partial thickness” sample of the skin (meaning only part of the layers of the skin in the area of the biopsy are removed, such as the epidermis layer only). Alternatively, they may take a “full thickness” sample of the skin (meaning the surgeon cuts through the epidermis and full thickness of the dermis down to the subcutaneous tissue to take a sample that includes all layers of the skin tissues).
• Tangential refers to a slicing motion with a blade. In this type of biopsy, the physician takes a “slice” of the skin and is taking a “partial thickness” sample of the skin lesion, usually taking only the epidermis. The physician may take part of the underlying dermal layer if needed, but in either case, is not cutting full thickness through the skin and taking epidermis and the full thickness of the dermal layer. Some synonyms for tangential include “curetting,” “scooping,” or “shaving” to obtain a biopsy, and you may see these terms used in procedure reports.
• A punch biopsy involves taking a “full thickness” column of tissue from a lesion using a punch tool. Punch tools come in different sizes so you may see a punch tool mentioned along with a size in millimeters (e.g., 12.0 millimeter punch tool was then used to obtain a biopsy)
• An incisional biopsy as the name suggests involves creating an incision with a blade. The incision may either be vertical or may involve cutting out a “wedge” of tissue. This type of biopsy is “full thickness” where tissue through the full thickness of the epidermis and dermis is excised and even the underlying subcutaneous fat may be removed if needed.

Key Guidelines:Now that we understand some key terms used in these code descriptions, we also need to be aware of rules about how the codes should be used.

• These codes can be used for biopsies anywhere in the body as long as the biopsy is of a “skin lesion.” The codes are not restricted to use for a specific anatomic site(s). For biopsy from tissues other than the skin, there are codes throughout the surgery section of CPT to represent those biopsies. For example, if a surgeon documented a biopsy of the anterior two-thirds of the tongue, you would report CPT 41100 rather than one of these skin biopsy codes.

• When coding more than one biopsy during the same case, you can only code one primary/parent code for the most extensive biopsy performed. You would then report all additional biopsies with add on codes. Example: A physician performs an incisional wedge biopsy of a lesion on the right forearm. He then performs a punch biopsy of a second lesion on the upper arm near the shoulder. In this example, you would code CPT 11106 for the most extensive biopsy technique (the incisional biopsy) and code add on code 11105 for the punch biopsy of the second lesion. How did I decide which primary biopsy and add on biopsy code to use? You can determine this both through checking your NCCI edits and your CPT guidelines. If I check NCCI edits between 11106 (first lesion incisional biopsy) and 11104 (first lesion punch biopsy), I see that CPT 11106 has higher total RVUs and is the column 1 (or more comprehensive) code in the NCCI edit. This confirms that the primary code CPT 11106 should be coded and that the punch biopsy should be reported with the add on code using NCCI edits. Your CPT parenthetical notes under these codes can also be useful guides to determining which primary codes the add on may be reported with. For example, underneath CPT 11105 (add on code for each additional lesion biopsied with a punch technique), it tells us to code first 11104 (a first lesion punch biopsy) or 11106 (a first lesion incisional biopsy). Underneath CPT 11107 though (add on code for each additional lesion biopsied with an incisional technique), it tells us to code first CPT 11106 (a first lesion incisional biopsy). So in our example here, we could not have reported CPT 11104 (first lesion punch biopsy) and CPT 11107 (add on code for each additional lesion biopsied with an incisional technique) without violating the CPT guidelines.

• The tangential biopsy codes which again involve a “slicing” of “shaving” motion can appear similar to other CPT codes like shave removals of lesions. To decide whether to code a tangential biopsy code or a shave removal code, look at the intent of the procedure. If the intent is to obtain tissue for a diagnosis/pathology, code the procedure as a tangential biopsy. If the intent is to completely remove the lesion, code the procedure as a shave removal.

• The biopsy codes include “simple closure” when performed. That means that it is not necessary for the surgeon to close the wound after the biopsy in order to use these codes, but that if he does so, and the closure is “simple” you do not get to report a separate code for that closure. The CPT guidelines define simple repair as “one layer closure” (meaning one layer of stitches is placed or techniques such as tissue glue that do not involve the use of stitches are used). In the rare event that a biopsy results in the need for a more extensive intermediate repair (i.e., layered closure where at least one layer is in the subcutaneous tissues or deeper) or complex repair (i.e., more than layered closure involving techniques such as debridement, stents, retention sutures, extensive undermining, or scar revision), you may report a separate CPT code for the repair.

Let’s look at an example together to put these definitions and guidelines into practice:

Example #1: A 30 year old male presents with a raised skin lesion on the right thigh that has grown and changed in color over the past few weeks. He is brought to the procedure room today for tissue diagnosis.

After prep and drape, local anesthetic was applied around the right thigh lesion. A scalpel was used to shave a 0.5 cm strip of epidermal tissue.from the lesion. Bleeding was controlled and patient tolerated the procedure well. He will follow up with me in 1 week for pathology results.

Answer example #1: The bold portions of the procedure note help us with our code selection. First of all we see in the history provided that the intent of the procedure is “tissue diagnosis” confirming this is a biopsy. We also see the indication is a “skin lesion” of the thigh confirming that we should select a code from the skin lesion biopsy codes in the integumentary section of CPT rather than from another section of the CPT manual.

From there, we see the surgeon using a scalpel (a type of blade) to “shave” epidermal tissue only. So the technique for biopsy is a “shave method” and this is a “partial thickness” sample since only the epidermal tissue is taken. These details confirm the biopsy type is tangential. Finally, we see again the physician stating the patient will follow up for biopsy results in 1 week, again confirming intent here is to obtain a biopsy.

Since we have only one skin lesion and that lesion is biopsied using a tangential technique, we will report CPT 11102. 

We are continuing our series on notable changes for CPT in 2019. Another area of the code manual that received a pretty extensive overhaul involved the codes for FNA biopsies. The acronym FNA stands for “fine needle aspiration.” In this technique, the surgeon typically aspirates fluid for biopsy using a fine gauge needle (he/she will often use a 22 or 25 gauge needle in this procedure). The surgeon then withdraws fluid (e.g., from a cyst) or may withdraw clusters of cells from a solid mass and that specimen is sent to pathology to obtain a diagnosis. The term “biopsy” was added to the FNA codes in 2019 to clarify that these codes should not be reported if the intent of the procedure is simply to drain fluid (there are other codes for fluid drainage in CPT). The intent of these FNA biopsy codes is to report use of a fine gauge needle to withdraw a specimen for purposes of biopsy (i.e., getting a diagnosis from the specimen).

In 2018, we only had two codes available for an FNA biopsy: CPT 10021 for an FNA biopsy without imaging guidance and 10022 for an FNA biopsy with imaging guidance. For CPT 10022 for the FNA biopsy with imaging guidance, you then had to add a second code to represent the exact type of imaging guidance used (77002 for fluoroscopy, 76942 for ultrasound, 77012 for CT guidance, or 77022 for MR guidance).

For 2019, though, we now have combination codes that capture FNA biopsy performed using specific types of imaging guidance (e.g., FNA biopsy with fluoroscopic guidance is all captured with a single code). The codes have also been designed to include primary codes for FNA biopsy of the first lesion and add on codes for each additional lesion where FNA biopsy is performed using the same type of imaging guidance.

Let’s start by looking at all of the new codes and their descriptions:

FNA Biopsy Without Imaging Guidance

10021  -Fine needle aspiration biopsy, without imaging guidance; first lesion

+10004 –Fine needle aspiration biopsy, without imaging guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy With Ultrasound Guidance

10005 –Fine needle aspiration biopsy, including ultrasound guidance; first lesion

+10006 –Fine needle aspiration biopsy, including ultrasound guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with Fluoroscopic Guidance

10007 –Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion

+10008 –Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with CT Guidance

10009 –Fine needle aspiration biopsy, including CT guidance;first lesion

+10010 –Fine needle aspiration biopsy, including CT guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with MR Guidance

10011 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

+10012 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

With the creation of these new codes for FNA biopsy, there are a couple of key guidelines to keep in mind:

• You can no longer report imaging guidance codes 77002, 76942, 77012, or 77022 with the FNA biopsy codes to report the imaging guidance used to perform the FNA biopsy itself or a core biopsy on the same lesion during the same encounter. Again the new combination codes already include the work of the FNA biopsy plus the specific form of imaging guidance in a single code. Coding tip: It would be permissible to report one of these imaging codes with an FNA biopsy code if the imaging was used to complete a procedure other than the FNA biopsy or a core needle biopsy on the same lesion during the same encounter.

• If “multiple passes” (i.e., multiple FNA biopsies) are obtained of the same lesion, you will still report only one unit of the FNA biopsy code that describes how that FNA biopsy was obtained. For example, if a surgeon performs an FNA biopsy under CT guidance for a nodule in the left thigh and he makes four passes into that nodule during the procedure to ensure he obtains adequate tissue for pathology, you will code CPT 10009 with only 1 unit. Even though four “passes” were made, he is biopsying just one lesion so you only code 1 unit of the CPT.

• When multiple lesions are addressed with FNA biopsy during the same encounter and all lesions are biopsied using the same type of imaging guidance, you report the primary code for the first lesion biopsied and report the add on code for the second and all additional lesions. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid also under ultrasound guidance, you will code CPT 10005 for the first nodule and CPT 10006 for the second nodule.

• When multiple lesions are addressed with FNA biopsy during the same encounter but lesions are biopsied using different types of imaging guidance, you report the primary code for the first lesion biopsied, picking the primary code that accurately describes the type of imaging guidance used, and then you report a second primary CPT code for the additional lesion biopsied using a different type of imaging guidance. Modifier 59 (or modifier XS if your payer like Medicare accepts the EPSU modifiers) will be required on the second primary CPT code to indicate that more than one site was biopsied. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid under fluoroscopic guidance, you will code CPT 10007 for the nodule biopsied using fluoroscopic guidance and CPT 10005 with modifier 59 (or modifier XS if the payer like Medicare accepts the EPSU modifiers) for the second nodule biopsied under ultrasound guidance. The coding is changed in this scenario because each nodule was biopsied using a different type of imaging guidance. Coding tip: I decided which CPT code needed the modifier 59 based on the NCCI edits. The modifier 59 would go on the column 2 code (i.e., the potentially bundled code in the NCCI edit pair). You can download a copy of the NCCI edit tables from Medicare’s website at the following link: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. When you get to the website, download all files that start with “Practitioner PTP Edits v25.0” (there are four files in total). You can also check edits in online coding software like 3M, Encoder Pro, and Supercoder (many coders find this to be an easier method of checking their edits). Just be sure to apply the modifier 59 (or XS) to your column 2 code.

I hope this article helps you to understand the changes for these codes in 2019 and how to use these codes correctly. If you have any questions about this topic or any of the new 2019 CPT codes that you would like to hear more about, head over to the “contact” tab and send me your question. I am always happy to hear from my readers and provide content that will help you in your daily work.