Updated on: September 23, 2013

Making a Case for Possible ICD-10 Confusion: Breast Procedure Terminology

By Mary C. Maloy, CPC, CPC-H, RHIT, BS
Original story posted on: November 28, 2012

Operative reports for breast procedures often confuse coding professionals because physicians use certain phrases—such as biopsy, lumpectomy, and excisional biopsy—interchangeably in their documentation.

Just because physicians know what they mean does not mean that coding professionals will know unless they have an understanding of the procedure and the specificity of the terms used. When ICD-10-PCS comes around, assignment for these procedures will continue to be a dilemma due to the increased specificity in the new system.

For example, an excision will be assigned to a different code than a biopsy. In order to determine whether an “excisional biopsy” is an excision or a biopsy, and assign the correct code, operative reports must be read carefully.

A breast excision or removal will not need a “qualifier” as the seventh digit, but since a biopsy would be diagnostic, it would, therefore, need a qualifier to indicate that the procedure was performed for a diagnostic purpose. However, be aware that qualifiers have different meanings depending on the procedure and body part.

Determining the physician’s intent when reading the operative report will be critical to assigning an ICD-10-PCS procedure code.  Notice in the report below that the physician uses both words: excision and biopsy.

DOCUMENTATION

Preoperative Diagnosis: Newly discovered left breast mass

Postoperative: Newly discovered left breast mass

Operation: Wide localized excision biopsy of left breast

The patient was brought to the operating room and placed in the supine position. General anesthesia was LMA-induced. I was satisfied that the wire passed through the mass, and an ultrasound was sent to confirm this. I cut the wire approximately 2 cm from the skin, and the left breast was prepped and draped in a sterile fashion.

After first infusing the skin and soft tissue with local anesthetic, which in this case was 0.5% Marcaine with epinephrine, a 4-cm curvilinear incision was made approximately 3 cm towards the nipple from the axis of the wire and in the outer lower quadrant of the left breast. The underlying soft tissue was dissected through to the wire, which was grasped and brought through the insertion point and out to a skin incision. This was clamped in place with a Lahey clamp, and a column of tissue around the wire was taken using sharp dissection until the end of the wire was found. It was noted that the wire had passed 2.4 cm beyond the mass and so the tissue was amputated at the end of the wire. The tissue was marked with the long lateral and short superior suture and sent to the radiologist. The wound was irrigated and dried. Multiple small areas of bleeding were addressed with careful Bovie cauterization. Again, the wound was irrigated and dried. Hemostasis was noted to be excellent.

The radiologist was called into the room and stated that the mass was within the excised specimen by post excision mammogram of the specimen. The wound again was inspected, and hemostasis was noted to be excellent. An additional 10 cc of 0.5% Marcaine with epinephrine was infused in the tissue around our excision. The deep dermis was closed with 5 separately placed 3-0 Vicryl sutures, and the skin was closed with a running 4-0 Vicryl subcuticular stitch. The wound was dressed with 2x2 gauze pad followed by a clear Tegaderm.

Patient was in stable condition to the post-anesthesia care unit.

CODE ASSIGNMENTS

The following CPT code would be assigned for the above procedure:

19125 Excision, breast lesion, preop placement, radiological marker, open; single

Both the ICD-9 and ICD-10 diagnosis codes and procedure codes are listed below. Note that in the case of the ICD-10 PCS (procedure) system, each character has a very specific identifying function.

ICD-9-CM Diagnosis Code: 611.72       Signs and symptoms in breast; lump or mass in breast

ICD-10-CM Diagnosis Code: N63         Unspecified lump in breast

ICD-9-PCS Code: 85.21                         Local excision of lesion of breast

ICD-10-PCS Code: 0HBU0ZX                Excision of left breast, open approach

First character of “0” identifies section:

Medical and surgical

 

Second character of “H” identifies body system:

Skin and breast

 

Third character of “B” identifies root operation:

Excision

Fourth character of “U” identifies body part:

Breast, left

Fifth character of “0” identifies approach:

Open

Sixth character of “Z” identifies device:

None

Seventh character of “X” identifies qualifier:

Diagnostic

Coding Tips

  • The ICD-9-CM code offers no further specificity regarding which breast the procedure was performed, but this is included in the ICD-10 procedure code.
  • The RT modifier must be appended to the CPT code in order to show the laterality of the procedure.
  • Since this mass was unknown, this procedure was for diagnostic purposes, and the qualifier “X” would be assigned as the seventh character.
  • If the mass was known to be malignant and the excision was for removal of the mass, the qualifier would be “Z,” indicating it was not diagnostic.

About the Author

Mary C. Maloy is an AHIMA-approved ICD-10 Instructor and a senior healthcare consultant for Panacea Healthcare Solutions, Inc.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.