Five Steps for Mastering Tricky Breast Procedure Coding

Coding and billing for breast surgical procedures can be challenging, especially when it comes to understanding clinical terminology for surgical and office-based breast care. Coders, billers, office managers, and clinical staff such as RNs and MAs all have a stake in improving documentation and submitting accurate coding of surgical breast procedures and clean claims, and receiving quicker reimbursement from third party payers.

Here’s how to be sure you understand the latest strategies and coding concepts for correct billing for breast procedures in a physician-based practice.

Key Breast Coding Terms and Issues

If you’re new to coding for a surgeon who performs breast procedures, or even if you just need a refresher, first make sure you’re familiar with the terminology. Common breast coding terminology, common terms and diagnostic conditions associated with breast procedures include the following:

• Incision breast coding for cysts of breast, drainage of deep abscesses, and injection procedure for ductograms
• Excision breast coding for breast biopsies, imaging of specimens, ultrasound guidance and magnetic resonance guidance
• Fine needle aspiration with and without imaging guidance
• Mammography and 2018 CPT® code changes in relation to breast care
• Mammoplasty, or reconstructive breast surgery, including augmentations, reductions and axillary node dissections
• Exploratory breast codes covering nipple exploration, excisions of lactiferous duct fistula and breast lesion excisions
• Localization device placement performed without a biopsy at the same session, magnetic resonance guidance, ultrasound guidance and stereotactic guidance
• Correlating ICD-10-PCS coding on the hospital side
• Using HCPCS codes for billing Medicare or Medicaid

Five Steps to Accurate Coding

Clinical and office staff alike need best practices and helpful hints to improve their practice’s financial bottom line. Correct AIUM and medical necessity documentation often start with the operative report and the pathology notes relating to the procedures above.

Strategies to help implement the correct clinical documentation processes include a five-step operative surgical coding process to accurately code surgical breast procedures in CPT® and PCS breast procedures:

1. Review the operative header to find the procedure the physician plans to perform. The operative header is located at the beginning of the operative report.
2. Review the operative detail to see what procedure(s) the surgeon did perform and for what diagnoses. Query the physician when necessary.
3. Verify the diagnoses listed in both the operative and pathology reports, especially when dealing with tumors and neoplasms.
4. Use your medical dictionary/encyclopedia to clarify any medical terminology you don’t understand.
5. Assign the proper CPT and ICD-10 code(s).

Confusing Coding for Lumpectomies

For example, a review of an operative report might reveal a lumpectomy with axillary lymphadenectomy, which would be assigned CPT code 19302, and a removal of intact mammary implant, which would be 19328. If you review the pathology report, you would assign ICD-10 codes C50.612 for malignant neoplasm of axillary tail of left female breast (lateral and axillary tail).

In this example, note that lumpectomies are still noted in CPT as part of the mastectomy (removal of entire breast) codes. However, a lumpectomy does not remove the entire breast—only a portion of it, and lymph nodes complicate the situation. CPT gives you two codes to report lumpectomies—codes 19301 and 19302, the latter of which involves lymph node excision.

Stay Abreast of the Changes

Multi-specialty coding consultant and AHIMA-approved ICD-10 trainer Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, addresses these difficult breast procedure coding issues in an audio conference for ProfEdOnDemand, “Coding and Billing for Breast Procedures.” Lori-Lynne will guide you through the latest updates to ICD-10 and CPT codes and explain the five-step process, offering examples and expert insights to help you get your breast procedure coding into tip-top shape for 2018.