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. What are the ICD 10 CM and CPT Codes for this case?
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The ICD10-CM code for this case is - D24.2
The CPT code for this case is- 19125 LT
Explanation:
- 19081-19272 is the CPT code for surgical excision procedures on breast.
- For left breast the code is 19125.
- For right breast the code is 19126.
- The ICD-10 CM codes are the specific billable codes depending upon the diagnosis.
- For female left breast benign lesion the ICD-10 CM code is D24.2
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