CPT CODE SOFT TISSUE MASS EXCISION SKIN

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. I cut the wire approximately 2 cm from the skin, and the left breast was prepped and draped in a sterile fashion.ДЄfter 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. I was satisfied that the wire passed through the mass, and an ultrasound was sent to confirm this. The patient was brought to the operating room and placed in the supine position. Operation: Wide localized excision biopsy of left breast Postoperative: Newly discovered left breast mass Preoperative Diagnosis: Newly discovered left breast mass Notice in the report below that the physician uses both words: excision and biopsy. However, be aware that qualifiers have different meanings depending on the procedure and body part.Дetermining the physicianвЂ™s intent when reading the operative report will be critical to assigning an ICD-10-PCS procedure code. In order to determine whether an вЂњexcisional biopsyвЂќ is an excision or a biopsy, and assign the correct code, operative reports must be read carefully.ДЄ breast excision or removal will not need a вЂњqualifierвЂќ 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. 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.ДЇor example, an excision will be assigned to a different code than a biopsy. 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. 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.

Cpt code soft tissue mass excision