breast surgery coding 2010

1

Page 2

Navigant Consulting, Inc.

Breast Surgery Coding

for Hospital Outpatients and Physicians

Page 3

Your Speakers . . . Both speakers are based out of the NCI Baltimore office and workprimarily with hospital clients in the state of Maryland to provide consulting services onoutpatient coding and documentation improvement, billing compliance and middle revenuecycle management.

Caroline “Rader” Znaniec, Associate Director [email protected]

Ms. Rader has worked in healthcare for 15 years in such positions as Corporate ComplianceOfficer, Auditor and Operations Manager. She is the designated service line leader withinNCI’s Healthcare Practice for CDM and Charge Integrity Services, including NCI’s latestoffering – Outpatient CDI. She has been an author and is a speaker for the Health CareCompliance Association, a national and state (Maryland and Florida) level speaker for theAmerican Health Information Management Association, a speaker for various New YorkState Health Care Financial Management Association Chapters, and the Maryland HealthCare Financial Management Association.

Nikisha Small, Managing Consultant [email protected]

Ms. Small has extensive experience in professional and facility coding, revenue cycleoperations, denials management and practice management. Prior to joining NCI, Ms. Smallworked in Health Information Management, Physician Education, Compliance, and Codingand Reimbursement with two of the nation’s leading academic facilities.

2

Page 4

Overview

Section 1

Overview

» Many men and women who are diagnosed with breast cancer, along with those with other breast disease processes, can be effectively treated now in an outpatient setting, although some procedures also may be provided on an inpatient bases.

» Understanding the differences between the various diagnostic and treatment options available is an integral skill for any coder.

» Common errors when reviewing coding of breast surgery procedures

› Incomplete capture of diagnoses

› Bundling/Unbundling of procedures

› Coding inaccuracies (e.g. biopsy type)

› Lack/Misuse of modifiers

Page 5

Page 6

Diagnosis Coding

Section 2

3

Diagnosis Coding

» When assigning diagnosis codes for a patient with a breast disease carefully review all information available

› History and Physical (H&P),

› Procedure Report,

› Pathology or Cytology Report (if applicable), and

› Any other pertinent documentation in the medical record

» Common Diagnosis Categories

Benign 610 and 611, Disorder of Breast

Male or Female

Malignancy 174, Female or 175, Male

172 or 173 if skin only

Cancer In Situ 233

Page 7

Page 8

CPT Procedure Coding

Section 3


» Modifier Use

› Modifiers should be assigned to all breast procedure CPT codes to ensure appropriate specificity;

‒ RT (right side)

‒ LT (left side)

‒ 50 (bilateral procedure)

› Any and all CCI edits should be considered

› When appropriate apply modifier -59 (distinct procedural service)

› More information

‒ http://campus.ahima.org/audio/2008/RB041708.pdf

Page 9

4


» Breast Fine Needle Aspirations (FNA)

› Less invasive option for patient when suspicious lesion is detected

‒ Commonly performed in office or clinic setting

‒ A fine needle is inserted through the skin of the breast into the suspicious area and fluid or clusters of cells are removed for cytologic analysis

‒ May be further recommended to have an incisional or excisional biopsy procedure

› FNA services are reported with one of two codes, differentiated by whether imaging guidance was used to accomplish the procedure

‒ 10021 (Fine needle aspiration; without imaging guidance)

‒ 10022 (Fine needle aspiration; with imaging guidance)

◦ Guidance may include CT, US, Fluoroscopy, MRI

◦ Guidance use must be clearly documented

◦ Imaging guidance CPTs are reported in addition

◦ Metallic clip placement (CPT 19295) can be added in

addition

Page 10

2010


» Breast Puncture Aspiration

› More invasive option than FNA for patient that has a fluid filled cyst

‒ Commonly performed in office or clinic setting

‒ This procedure involves the physician inserting a syringe needle through the skin of the breast into the cyst and fluid is evacuated, thus reducing the size of the cyst.

› Puncture aspirations are reported with one or two codes

‒ 19000 (Puncture aspiration of cyst of breast)

‒ 19001+ (each additional cyst)

‒ Imaging is identified by use of a separate CPT describing the modality

Page 11


» Breast Biopsies

› Includes

‒ Needle Core

‒ Stereotactic

‒ Incisional

‒ Excisional

› Each has their own coding guidelines

Page 12

5


» Needle Core Breast Biopsies

› A large gauge needle is inserted through the skin of the breast and into the suspicious tissue

› The needle is removed along with a core of breast tissue

› Coding is dependent on the use of imaging guidance

‒ 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance)

‒ 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance)

◦ Imaging guidance is captured in addition even though the description of the surgical procedure indicates “using imaging guidance”

› Each insertion of the needle can result in multiple core samples, commonly up to 5 from a single lesion

‒ The CPTs are reported per lesion sampled

› Imaging of the specimen should also be identified

‒ 76098 (Radiological examination, surgical specimen)

‒ Performed to provide the surgeon with immediate results

Page 13


» Stereotactic Breast Biopsies

› An automated vacuum assisted or rotating biopsy device is inserted through the skin into the suspicious breast tissue and a core of suspect tissue is removed for biopsy

› The needle is removed along with a core of breast tissue

› A single CPT code describes the procedure

‒ 19103 (Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance)

◦ Imaging guidance is captured in addition even though the description of the surgical procedure indicates “using imaging guidance”

› A single insertion of the needle/device can result in multiple samples

‒ Its not expected that multiple insertions would occur

› Imaging of the speciment should also be identified (CPT 76098)

› Keywords to identify a stereotactic breast biopsy by device utilized

Mammotome Suros

Encor ABBI

MIBB (Minimally Invasive Breast Biopsy)Page 14


» Incisional Breast Biopsies

› Incision is made into the breast near the site of the suspicious mass and a sample is removed

› Code when the incision is closed and no other procedure performed

‒ 19101 (Biopsy of breast; open, incisional)

› If another service (more extensive) is performed immediately the initial biopsy is not coded

› Imaging guidance is identified by use of a separate CPT describing the modality

› Imaging of the speciment should also be identified (CPT 76098)

Page 15

6


» Excisional Breast Biopsies

› The entire mass is excised for biopsy

› May include localization before or during excision procedure

‒ A needle placed into the breast lesion preoperatively to assist in exact identification of the affected suspicious tissue

‒ A separate code for the placement of the localization device should be assigned separately to the excision procedure

◦ 19120 (Preoperative placement of needle localization wire, breast)

◦ 19121+ (each additional lesion)

Page 16

HOSPITAL CDM TIP

If the preoperative placement is performed outside of the surgical procedurethis should be noted. This can occur in radiology and not in the operatingroom. In this case, hospitals should understand who/where the preoperativeplacement will be captured, documented and coded.


» Excisional Breast Biopsies (continued)

› CPT coding should reflect an “excision” and not a “biopsy”

‒ Actual codes are dependent on use of localization device

◦ No Device

▫ 19120 (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, 1 or more lesions)

▫ Code should only be reported once, regardless of number of lesions excised through the same incision

▫ If multiple separate incisions, report more than once with modifier

◦ Device

▫ 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion)

▫ 19126+ (each additional lesion separately identified by a preoperative radiological marker)

▫ These codes include the preoperative placement of a needle localization device (e.g. wire or clip)

Page 17


» Mastectomy

› Broad term to describe any therapeutic excisions of breast tissue

› Mastectomy CPT procedures are unilateral by code definition

‒ Append modifier -50 for bilateral procedures

› There are different techniques and nomenclature that will determine the appropriate procedure coding

‒ Partial

◦ Lumpectomy,

◦ Quadrantectomy, or

◦ Segmental mastectomy

‒ Simple and “Modified”

‒ Subcutaneous

‒ Radical

‒ Radical and “Modified”

Page 18

7


» Partial Mastectomy

› The lesion or mass is excised from the breast, along with a margin or rim of healthy tissue

‒ “attention to adequate surgical margins”

› 19301 (Mastectomy, partial {e.g. lumpectomy, tylectomy, quadrantectomy, segmentectomy)

› 19302 (Mastectomy, with axillary lymphadenectomy)

‒ Assign if the procedure includes the excision of axillary lymph nodes

Page 19

» Simple “Modified” Mastectomy

› Includes the removal of all breast tissue, along with portion of skin and nipple through elliptical incision

› 19303 (Mastectomy, simple, complete)


» Subcutaneous Mastectomy

› Similar to simple with the exception of the extent of the excision

‒ Simple

◦ The breast is dissected from the pectoral fascia and from the skin

‒ Subcutaneous

◦ The breast tissue is removed, but the skin and pectoral fascia remain

› 19304 (Mastectomy, subcutaneous)

Page 20


» Radical Mastectomy

› Most extensive of mastecomy procedures

‒ Involves dissection of breast, overlying skin, pectoralis major and minor musles and the axillary lymph nodes

‒ All are removed as a single specimen

› Coding dependent on excision of axillary and/or internal mammary lymph nodes

‒ 19305 (Mastectomy, radical, including pectoral muscles, axillary lymph nodes)

◦ Axillary lymph nodes only

‒ 19306 (Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes {Urban type operation)

◦ Axillary and internal mammary lymph nodes

› A “modified” mastectomy spares the pectoralis muscles

‒ 19307 (Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle)

Page 21

8


» Breast Prosthesis

› Breast prosthesis insertion is often performed at the same surgical episode as the mastectomy, or can be inserted later as a separate procedure

› Coding differs on timing of procedure

‒ 19340 (Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction)

◦ Performed during same surgical session

‒ 19342 (Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction)

◦ Performed at a later date

› Can also occur when the patient has undergone mastopexy or another reconstructive breast procedure

Page 22


» Breast Reconstruction

› There are various approaches to breast reconstruction

‒ Latissimus Dorsi Flap

‒ Transverse Rectus Abdominis Myocutaneous Flap (TRAM)

‒ Free Flap

Page 23


» Latissimus Dorsi Flap

› The physician dissects a portion of the latissimus muscle from thepatient’s back; the muscle-skin flap remains attached to a main arteryand is then rotated to the front of the chest through a tunnel under thepatient’s armpit so that it extends through to the mastectomy incision

› Flap is attached to the chest wall and adjacent muscles for the mostaesthetic appearance

› 19361 (Breast reconstruction with latissimus dorsi flap, without prosthetic implant)

‒ Procedure only

› 19340 (Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction)

‒ Add on if implant also inserted

Page 24

9


» Transverse Rectus Abdominis Myocutaneous Flap (TRAM) Breast Reconstruction

› A muscle/skin flap transfer in which the rectus abdominis muscle is divided, but kept attached to its blood supply. It is passed through a connecting tunnel between the elevated chest skin and the inferiorly positioned flap. The muscle is contoured to make a breast mound.

› 19367 (Breast reconstruction with transverse recturs abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site)

‒ One pedicle flap

› 19368 (with microvascular anastomosis (supercharging)

‒ If additional microvascular anastomosis for connecting blood vessels is provided

› 19369 (Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site)

‒ If muscle/skin complex having two pedicles or both sides of the rectus abdominis are elevated; bilateral or hemiflaps

Page 25


» Free Flap Breast Construction

› Breast reconstruction with the use of a free flap involves excision of a completely free flap of skin, fat and muscle from another site on the patient, typically the thigh or buttocks.

› The excision includes careful dissection of vascular channels, which are anastomosed or attached to the mastectomy site via a microvascular technique to ensure a viable blood supply

› 19364 (Breast reconstruction with free flap)

Page 26


» Post Breast Reconstruction

› After reconstructive breast surgery procedures, it may be necessary to return for further surgery related to the previous procedure, particularly if an implant is involved.

‒ Removal of Intact Mammary Implant

‒ Removal of Mammary Implant Material

‒ Periprosthetic Breast Capsulotomy

‒ Periprosthetic Breast Capsulectomy

‒ Breast Reconstruction Revision

‒ Chest Wall Tumor Procedures

Page 27

10


» Removal of Mammary Implant Material

› A breast implant is not intact and has leaked, or the material hasotherwise migrated from its original location

› May require removal by a piecemeal approach.

› An incision is made and the implant material is carefully dissected

› 19330 (Removal of mammary implant material)

‒ Removal only

› 19340 (Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction)

‒ Add on to indicate replacement

Page 28


» Periprosthetic Breast Capsulotomy

› After breast implantation, an extensive capsule may form around theimplant,

› An incision is made around the capsule’s circumference, with noremoval of tissue

› 19370 (Open periprosthetic capsulectomy, breast)

» Periprosthetic Breast Capsulectomy

› The fibrous breast implant capsule may progress to a point in which thedecision is made to remove it, along with the scarred tissue

› A circumferential incision is made around the implant, the contractedcapsule is excised from the breast tissue and the prosthesis is removed.

› 19371 (Periprosthetic capsulectomy, breast)

Page 29


» Breast Reconstruction Revision

› A reconstructed breast may require some revision, most commonly forasymmetry.

› An incision is made and the tissues may be rearranged or secured withsutures to revise the shape of the breast

› The existing implant may be replaced and excess skin or tissue may beremoved

› 19380 (Revision of reconstructed breast)

Page 30

11

Page 31

Imaging Guidance

Section 4

Imaging Guidance

Page 32

» Imaging Guidance

› Image guidance refers to the use of an imaging modality to identify theexact location of the area to be treated or sampled

› Imaging is also used to ensure that the needle is placed in the correctlocation to obtain the biopsy

› For most drainage, aspiration, and biopsy procedures. imaging is notincluded in the base code and should be reported separately

› The modality chosen depends on the site and characteristics of the fluidcollection or lesion

› Documentation of needle or catheter tip location is a required (AmericanCollege of Radiology) ACR standard

› It is found that some modalities are not mentioned in the AMA crossreferences, but may be utilized, and these do not present a NCCI edit

‒ Fluoroscopy and CT guidance are commonly omitted

Imaging Guidance

Page 33

MOST COMMON IMAGE GUIDANCE PROCEDURES

12

Imaging Guidance

Page 34

» Imaging Guidance

› Dependent on the clinical scenario, more than one modality may bereported when guidance is accompanied by additional imaging

‒ Must be a documented separately and represent different modalities

◦ Example:

▫ Ultrasound guided breast biopsy

▫ Mammographic post biopsy verification

Page 35

Frequently Asked Questions

Section 5


Page 36

Q1. Are breast biopsy procedures reported per lesion or sample? What aboutthe imaging guidance?

A1. When performing breast biopsies, if multiple breast biopsies are performed,the biopsy procedure code and radiological supervision and interpretation(imaging) codes are submitted per lesion and NOT per sample.

Q2. Is it appropriate to report a diagnostic magnetic resonance imaging (MRI)study code and an MRI guidance code when MRI guidance is performedfor breast biopsy?

A2. Yes, if a diagnostic MRI breast study is performed on the same day as theMRI-guided breast biopsy, it is appropriate to report the diagnostic MRI codeand the MRI guidance code, as well as the appropriate surgical code for thebreast biopsy. However, if a diagnostic MRI study has been performed on thesame day prior to the breast biopsy and MRI sequences are performed forlocalization purposes only, these sequences are part of the guidance andshould not be reported separately.

13


Page 37

Q3.How are multiple ultrasound-guided breast cyst aspirations of the samebreast reported?

A3. The number of breast cyst aspirations reported is based on the number ofbreast cyst aspirations performed. For example, if three breast cysts areaspirated under ultrasound guidance, it is appropriate to report 19000 once,for the first cyst aspirated, 19001 twice, for the second and third cystsaspirated, and 76942 three times, for the ultrasound guidance. Theultrasound image guidance is reported per cyst aspirated.

Q4. Can you report a breast biopsy code multiple times when multiplesamples are taken from the same lesion?

A4. No, if multiple samples are taken from the same lesion, the biopsy codeshould be reported only once. However, when separate lesions are sampledduring the same session, it is appropriate to report the biopsy code multipletimes based on the number of separate lesions sampled.


Page 38

Q5. How is the placement of a metallic localization clip reported when notperformed in conjunction with a breast biopsy or aspiration procedure?

A5. The placement of a metallic localization clip should be reported with theunlisted breast procedure code 19499. CPT code +19295 (Imaged guidedplacement, metallic localization clip, percutaneous, during breast biopsy oraspiration (list separate in addition to code for primary procedure) cannot bereported because it is an add-on code and it is specific to the placement of aclip during a biopsy or aspiration procedure.

Q6. Our physicians have noted the use of the Mammotome biopsy device, buthave described a core biopsy procedure. How should this be coded?

A6. The Mammotome biopsy device is a vacuum assisted device. Core samplesare obtained, but by AMA CPT definition the appropriate CPT would be19103, “Biopsy of breast; percutaneous, automated vacuum assisted orrotating biopsy device, using imaging guidance”. The imaging guidancewould also be reported, dependent on modality utilized.

Section 6

» A breast implant may require removal for a number of reasons, includinginfection, displacement, excessive capsule formation or pain. When theimplant is considered intact, has not ruptured and can be removed in onepiece, assign;

‒ CPT Code 19328 and add code 19430 if another implant is placed at the same surgical episode

‒ ICD-9-CM code 85.94 should be assigned for this procedure.

Page 39

Questions and Discussion

breast surgery coding 2010

Documents