Cases , Coding

Mark Gittleman, MD/

Dr. Gittleman's Coding Corner: Return to the OR to obtain clean margins following lumpectomy

Question: I performed a lumpectomy (CPT 19301) with final path report showing positive margins. I then returned to the OR a week later for a re-excision to obtain clean margins. How do I code for this procedure?

Answer: Again, use CPT code 19301 with modifier -58 (staged or related procedure during the postoperative period). In the operative report, indicate it is a planned return to the OR for a more extensive procedure than the original operation.

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