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Code This!

Scenario Week of April 06, 2010:
View Current Scenario

The patient is a 67-year-old female who presents for a stereotactic core biopsy.

Preoperative diagnosis: Right breast mass
Postoperative diagnosis: Benign calcifications in right breast

The procedure and risks were explained to the patient and consent was obtained.

Site 1 – Right stereotactic core biopsy
The right breast was positioned and images of the clustered micro-calcifications in the upper outer quadrant were obtained posteriorly. The breast was prepped for the procedure. The area was anesthetized with a local anesthetic, and a small incision was made in the breast. Using an 8 g Mammotome vacuum-assisted device, two passes were made through the area and two specimens were obtained. Specimen radiographs showed calcifications in some of the cores. The specimen was marked as core #1. A micromarker was placed at the site of the core biopsy. Postprocedure mammograms were performed to document placement of the clip.

The patient did not experience any complications during surgery.

Site 2 – Right stereotactic core biopsy
The patient’s right breast was positioned and images of the clustered micro-calcifications in the central region at the middle depth were obtained. The breast was prepped for the procedure, the area was anesthetized with a local anesthetic, and a small incision was made in the breast. Using an 8 g Mammotome vacuum-assisted device, two passes were made through the area and two specimens were obtained. Specimen radiographs showed calcifications in some of the cores. The specimen was marked as core #2. A micromarker was placed at the site of the core biopsy. Postprocedure mammograms were performed to document placement of the clip.

There were no complications and the patient was taken to recovery in good condition.

Assign the appropriate CPT, HCPCS, and ICD-9-CM codes.


CPT Codes
19103-RTBiopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance
19103-RT-59Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance
19295-RTImage guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration (List separately in addition to code for primary procedure)
19295-RT-59Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration (List separately in addition to code for primary procedure)
77031-RTStereotactic localization guidance for breast biopsy or needle placement (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation
77031-RTStereotactic localization guidance for breast biopsy or needle placement (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation
76098-59Radiological examination, surgical specimen
76098-59Radiological examination, surgical specimen


ICD-9-CM Code
793.89Other (abnormal) findings on radiological examination of breast

CPT Coding Rationale
Two separate lesions were biopsied with stereotactic guidance. Report the code for each biopsy and the guidance for each lesion. There were also mammograms performed on the biopsy specimen. The biopsies were performed on the right breast so modifier RT should be used. Modifier 59 can be added to indicate that there are not duplicate procedures.

ICD-9-CM Coding Rationale
This code includes calcifications of the breast. This is the most specific code that can be assigned.

 
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