Q&A: Surgical diagnostic staging procedure or excisional biopsy/lumpectomy?


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Q: Do we code the 1/15/14 procedure to biopsy code 02 or excisional biopsy/lumpectomy in the following scenario?

Patient had stereotactic core needle biopsy on 1/15/14 that revealed invasive ductal CA, margins are not stated within the pathology report. The mastectomy performed 3/2/14 showed no residual cancer.

A: Code procedure from 1/15/14 to biopsy code 02 – per the CoC we use the margin status from the biopsy pathology. We do not review the subsequent resection to determine margin status on the biopsy.