Coding Brief: Breast Localization Clips Placement and Mastectomy Procedures

 CPT Assistant, May 2021, Volume 31, Issue 5, page 11

For the Current Procedural Terminology (CPT®) 2018 code set, a new parenthetical note was added to the Breast subsection of the Integumentary System section that states: "[i]ntraoperative placement of clip[s] is not separately reported." Since publication of these changes, there have been questions about when to correctly report percutaneous placement of breast localization device(s) (19281-19288), such as a clip, when performed the same day but prior to a mastectomy procedure (19301-19307). This coding brief will clarify appropriate reporting of these separate services when performed on the same day.

Coding Tip

"Intraoperative" refers to the "skin-to-skin" work of an operative procedure. It does not include pre- or post-service work, which may include separately reportable procedures or services.

For the CPT 2020 code set, new guidelines were added in the introduction of the Breast subsection to instruct reporting the appropriate percutaneous image-guided localization device placement code(s) (19281-19288) when performed prior to an open breast biopsy or open excision of a breast lesion. This includes percutaneous placement of a breast localization device prior to the intraoperative (ie, skin-to-skin) component of an open mastectomy procedure.

During image-guided percutaneous clip placement, typically performed by a radiologist or surgeon, views are obtained which will be used for pre-surgical planning. For example, part of the preservice work for a partial mastectomy (19302) is to review the localization mammogram with the radiologist, who performed the needle-localization procedure, so that the surgeon can plan the optimal location of the skin incisions and operative approach to the area of concern.

A typical scenario is one that would involve a patient who undergoes image-guided percutaneous placement of a localization device (eg, clip or wire) in the radiology department, and later undergoes an open partial mastectomy in the operating room. If, for example, mammographic imaging were used to percutaneously place the device, the radiologist would report code 19281, Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance. The radiologist does not append a modifier to code 19281 if no other services were performed.

A less common scenario involves the surgeon performing the image-guided percutaneous placement of a localization device prior to starting an open mastectomy procedure, either in another suite, in the preoperative holding area, or in the operating room. If, for example, ultrasound imaging were used to percutaneously place the device, the surgeon would report code 19285, Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance, with modifier 59, Distinct Procedural Service, appended to indicate that the procedure was distinct from the mastectomy procedure. Note that Healthcare Common Procedure Coding System (HCPCS) modifier XE, Separate Encounter, may also be appropriately reported depending on the policy of third-party payers.

In summary, the intent of the parenthetical note of "(Intraoperative placement of clip[s] is not separately reported)" following the mastectomy codes was to disallow and prevent separate reporting of placing a device in the open mastectomy wound or cavity, for example, to mark the margins of the excision for future operations or services (eg, radiation therapy). This was to acknowledge the minimal work required to place a clip or wire in an open wound. The qualifying factor for reporting image-guided percutaneous localization device placement is that the device is not placed intraoperatively (ie, during the skin-to-skin portion of a mastectomy procedure), which would not be separately reportable.