Excision of a Lesion Identified By Pre-Operative Placement of a Marker

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August 7, 2014

Question:

Our surgeon performed an excision of two breast masses, same incision, that were preoperatively localized with placement of wires by the breast center radiologist. Our question: do we report 19125 and 19126, or, because there was only one incision, do we only report 19125?

Answer:

Thanks for your question. Based on the information provided, the correct way to report this procedure would be to report the primary procedure code 19125 and the add-on code, 19126.

CPT code 19125 is described in the 2014 CPT Manual as follows:

“Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion”

There are two key pieces of information in this definition to ensure accurate code selection:

  • The lesion is identified by a radiological marker
  • The code states “single lesion”

CPT code 19126, an add-on code, states, “each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure).”

Because CPT code 19125 describes a single lesion, you will report 19125 for the first radiologically marked lesion and use the add-on code 19126 for each additional radiologically marked lesion.