7. OPERATIVE REPORT

The patient had a wire localization performed by radiology and was taken to the operating room. Under local anesthesia of the left breast, was prepped and draped in a sterile manner. A breast line incision was made through the entry point of the wire, and a core of tissue surrounding the wire (approximately 1 × 2 cm) was removed using electrocautery for hemostasis. The specimen, including the wire, was then submitted to radiology, and the presence of the lesion within the specimen was confirmed. The wound was checked for hemostasis, and this was maintained with electrocautery. The breast tissue was reapproximated using 2-0 and 3-0 chromic. The skin was closed using 4-0 Vicryl in a subcuticular manner. Steri-Strips were applied. The patient tolerated the procedure well and was discharged from the operating room in stable condition. At the end of the procedure, all sponges and instruments were accounted for. Pathology report later indicated: Benign tissue, breast.

CPT code: _-LT
ICD10-CM code: _

The CPT codes for surgical excision procedures on breast range from 19081-19272. The code 19125 is for left breast and 19126 for right breast tissue excision procedure.

In a breast biopsy, the suspected breast tissue sample is removed and tested in the lab for malignancy. Treatment options depend upon the biopsy results.

CPT code varies according to the biopsy type, like needle or wire localization, stereotactic, surgical, or image- or MRI-guided biopsy. Since the above procedure involves only excision of left breast tissue through wire localization, the CPT code is 19125 Lt.

The ICD-10 CM codes are the specific billable codes depending upon the diagnosis. Since the lesion was diagnosed to be a benign lesion through Radiology, the ICD-10 CM code will be D24.2 (female left breast benign lesion).