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Question: I need help coding the following procedure notes:

A medial periareolar incision was created along a pre-existing well-healed incision from prior incision and drainage. Superficial dissection was commenced sharply and a small fistula tract with calcific change within the dermis was noted. Using a lacrimal probe, a fistula tract was easily passed into the 12:00 position for a distance of 4.5 cm. Multiple additional fistula tracts were identified emanating deep to the nipple in the lateral orientation and further medially. These were debrided using a small curette. The calcific changes within the breast were located primarily along the inferior aspect of the dissection planes. These were excised completely and passed off as a specimen to rule out granulomatous mastitis. The remainder of the surrounding breast tissue appeared denuded, discolored and fatty replaced. Hemostasis was ensured. The breast parenchyma was reapproximated after mobilization off the pectoralis muscle using several interrupted 3-0 Vicryl stitches. 0.25% Marcaine with epinephrine was used as local anesthetic. The skin was closed using several interrupted 3-0 Monocryl sutures followed by a running 4-0 Monocryl in a subcuticular fashion. Sterile dressings were applied. All needle and sponge counts were correct at the end of the case.

Would I use 19112 to code this?

South Dakota Subscriber

Answer: No, you would not use 19112 (Excision of lactiferous duct fistula) to code the case you described, because a partial mastectomy was not performed. Instead, the procedure involved excision of calcific changes and fistula tracts, debridement, and reapproximation of the breast parenchyma.

The most appropriate code for the case in question would be 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). This code is used when the surgeon removes a breast lesion and the surrounding tissue. The incision is then closed with sutures.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC