An official website of the United States government
Home
SEER Inquiry System - Report
Produced: 05/30/2025 10:54 AM
Question 20150024
Inquiry Details
References:
CoC CAnswer Forum
Question:
Surgery of Primary Site--Breast: How should the Surgery of Primary Site field be coded when a patient has a lumpectomy and an additional margin excision during the same procedure? See discussion.
Discussion:
Operative report indicates a wire localized lumpectomy was performed. The pathology report includes a final diagnosis for two specimens as follows:
A) LEFT BREAST, EXCISION: INFILTRATING DUCTAL CARCINOMA
B) LEFT BREAST, NEW DEEP MARGIN, EXCISION: BENIGN BREAST TISSUES AND BENIGN FIBROFATTY SOFT TISSUES; NO EVIDENCE OF NEOPLASIA.
The definition for Breast surgery code 23 is "Reexcision of the biopsy site for gross or microscopic residual disease". There is no indication whether the re-excision has to be a separate procedure or can be during the same procedure as the excisional biopsy (lumpectomy). Some hospital registrars in our region believe code 22 is more appropriate.
Answer:
Revised Answer
Assign code 22 when a patient has a lumpectomy and an additional margin excision during the same procedure.
According to the CoC, "Re-excision of the margins intraoperatively during same surgical event does not require additional resources; it is still 22. Subsequent re-excision of lumpectomy margins during separate surgical event requires additional resources: anesthesia, op room, and surgical staff; it qualifies for code 23."
