Coding guidelines for Breast procedure

1. Coding guidelines for Breast procedure

1.   Incision

2.   Excision

3.   Introduction

4.  Breast Reconstruction Procedure  

1. Definition of mastectomy

To removal of breast tissue including all lesions within the breast tissue,

1. Coding guidelines Mastectomy:
2. Breast excision code cannot be reported with mastectomy procedure when performed in same breast. If it is different laterality can be coded both (19110-19126) and  (19300-19307) with laterality modifier (RT or LT).
3. However, if the breast excision procedure precedes the mastectomy for the purpose of obtaining tissue for pathologic examination which determines the need for the mastectomy, the breast excision and mastectomy codes are separately reportable with 58 modifier.
4. Diagnosis was diagnosed before surgery breast excision procedure performed for additional pathology can be reported separately.
5. Diagnostic biopsies (e.g., fine needle aspiration, core, incision) to procure tissue for diagnostic purposes to determine whether an excision or mastectomy is necessary at the same patient encounter may be reported with modifier 58 appended to the excision or mastectomy code. However, biopsies (e.g., fine needle aspiration, core, incision) are not separately reportable if a preoperative diagnosis exists.
6.  Incision and closure procedures are included in breast procedure.
7. Sentinel lymph node biopsy is separately reportable when performed before a localized excision of breast or a mastectomy without lymphadenectomy. However sentinel lymph node biopsies, ipsilateral lymph node excisions are not separately reportable. Contra lateral lymph node excisions may be separately reportable with appropriate modifiers (i.e., LT, RT).

Lymph node biopsy codes are

1.   axillaries (CPT codes 38500 or 38525),

2.   deep cervical (CPT code 38510)

3.   internal mammary (CPT code 38530)

Important exclude procedure for mastectomy procedure

Breast reconstruction codes that include the insertion of a prosthetic implant shall not be reported with codes that separately describe the insertion of breast prosthesis.

CPT code 15734 (Muscle, myocutaneous, or fasciocutaneous flap; trunk) shall not be reported with breast reconstruction CPT codes 19357-19364 and 19367-19369 or breast prosthesis CPT codes 19340 and 19342 since a flap, if performed, is included in the reconstruction or prosthesis procedure.

Breast reconstruction procedures includes adjacent tissue transfer or rearrangement procedures when performed in same site of reconstruction procedure. If it is different site can be code both

Breast Reconstruction Procedure 

General coding guideline (integumentary system)

1. CPT codes 15851 and 15852 describe suture removal and dressing change, respectively, under anesthesia other than local anesthesia. These codes shall not be reported when a patient requires anesthesia for a related procedure (e.g., return to the operating room for treatment of complications where an incision is reopened necessitating removal of sutures and redressing). Additionally, CPT code 15852 shall not be reported with a primary procedure
2. Fine needle aspiration (FNA) biopsies (CPT codes 10004-10012, and 10021) shall not be reported with a biopsy procedure code for the same lesion. For example, a FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the provider/supplier shall report only one code, either the biopsy code or the FNA code. (CPT code 10022 was deleted January 1, 2019.)
3. The NCCI PTP edits pairing CPT codes 11102, 11104, and 11106 (Tangential, punch, or incision biopsy of single skin lesion) each with CPT codes 17000 and 17004 (Destruction of benign or premalignant lesions) are often bypassed by using modifier 59 or – X{ES}. Use of modifier 59 or -X{ES} with these NCCI PTP edits is only appropriate if the 2 procedures of a code pair edit are performed on separate lesions or at separate patient encounters. Refer to the “CPT Manual” instructions preceding CPT codes 11102, 11104, and 11106 for additional clarification about the CPT codes 11102-11107. (CPT codes 11100-11101 were deleted January 1, 2019.) 
4. The NCCI PTP edit with Column One CPT code 11719 (Trimming of no dystrophic nails, any number) and Column Two CPT code 11720 (Debridement of nail(s) by any method(s); 1 to 5) is often bypassed by using modifier 59 or -X{EPSU}. Use of modifier 59 or -X{ES} with the Column Two CPT code 11720 of this NCCI PTP edit is only appropriate if the trimming and the debridement of the nails are performed on different nails or if the 2 procedures are performed at separate patient encounters. 
5. If the code descriptor of a HCPCS/CPT code includes the phrase “separate procedure,” the procedure is subject to NCCI PTP edits based on this designation. CMS does not allow separate reporting of a procedure designated as a “separate procedure” when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach. 
6.  Most NCCI PTP edits for codes describing procedures that may be performed on bilateral organs or structures (e.g., arms, eyes, kidneys, lungs) allow use of NCCI-associated modifiers (modifier indicator of “1”) because the 2 codes of the code pair edit may be reported if the 2 procedures are performed on contralateral organs or structures. Most of these code pairs should not be reported with NCCI-associated modifiers when the corresponding procedures are performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit. The existence of the NCCI PTP edit indicates that the 2 codes generally should not be reported together unless the 2 corresponding procedures are performed at 2 separate patient encounters or 2 separate anatomic sites. However, if the corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers should generally not be used.
7.    If fluoroscopy is performed during an endoscopic procedure, it is integral to the procedure. This principle applies to all endoscopic procedures including, but not limited to, laparoscopy, hysteroscopy, thoracoscopy, arthroscopy, esophagoscopy, colonoscopy, other GI endoscopy, laryngoscopy, bronchoscopy, and cystourethroscopy. 
8. If the code descriptor for a HCPCS/CPT code, “CPT Manual” instruction for a code, or CMS instruction for a code indicates that the procedure includes radiologic guidance, a provider/supplier shall not separately report a HCPCS/CPT code for radiologic guidance including, but not limited to, fluoroscopy, ultrasound, computed tomography, or magnetic resonance imaging codes. If the physician performs an additional procedure on the same date of service for which a radiologic guidance or imaging code may be separately reported, the radiologic guidance or imaging code appropriate for that additional procedure may be reported separately with an NCCI-associated modifier if appropriate. 
9. CPT code 36591 describes “collection of blood specimen from a completely implantable venous access device.” CPT code 36592 describes “collection of blood specimen using an established central or peripheral catheter, venous, not otherwise specified.” These codes shall not be reported with any service other than a laboratory service. That is, these codes may be reported if the only non-laboratory service performed is the collection of a blood specimen by one of these methods.