This 47-year-old female patient has a palpable lump in her right breast and also a smaller lesion in the left breast that was identified on mammography. This lesion was also identified by a radiological marker on this visit. She had an excisional biopsy on both sides in an ambulatory surgery center. The specimen from the right breast was found to have breast malignancy with clear margins, and the smaller lesion on the left breast was found to have fibrocystic disease only. Which of the following diagnosis and procedure code sets is most appropriate?
a. 174.9, 610.1, 19120-RT, 19125-LT, 19290-LT
b. 611.72, 610.1, 19120-5
c. 174.9, 610.1, 19120-50, 19125-50, 19290-50
d. 174.9, 610.2, 19120, 19125-59, 19290
3. a. Separate CPT codes with RT and LT modifiers indicate that separate different procedures were performed on each breast for this patient. This is why the 50 (bilateral procedure) modifier should not be assigned. An excisional biopsy was performed on the right (19120) and an excisional biopsy via needle localization technique was performed on the left side (19125 & 19290). The final diagnosis of breast malignancy was made, which should be reported as the first-listed diagnosis (174.9), with a secondary code for the fibrocystic disease (610.1).