Question

A 76-year-old female had a recent mammographic and ultrasound abnormality in the 6 o'clock position of the left breast. She underwent core biopsies which showed the presence of a papilloma. The plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, we performed a generous excisional biopsy around the needle localizing wire including all of the methylene blue-stained tissues. The specimen was then submitted for radiologic confirmation followed by permanent section pathology. Once hemostasis was assured, digital palpation of the depths of the wound field failed to reveal any other palpable abnormalities. At this point, the wound was closed in 2 layers with 3-0 Vicryl and 5-0 Monocryl. Steri-Strips were applied. Local anesthetic was infiltrated for postoperative analgesia. What CPT® and ICD-10-CM codes describe this procedure? A. 19100, N63.20 B. 19285, C50.912 C. 19120, R92.8 D. 19125, D24.2

Answer 1

Step-by-step explanation:

The appropriate CPT® and ICD-10-CM codes for the described procedure are:

**C. 19120, R92.8**

Step-by-step explanation:

- **CPT® Code 19120:** This code represents "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, one or more lesions."

- **ICD-10-CM Code R92.8:** This code corresponds to "Other specified abnormal and inconclusive findings on diagnostic imaging of breast."

These codes reflect the excisional biopsy of the breast tissue performed in response to the abnormal mammographic and ultrasound findings, with the ICD-10 code indicating the abnormal findings on imaging that led to the procedure. Always ensure to use the most current coding guidelines and conventions.