19120

Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions

CPT code 19120 describes an open surgical excision of one or more breast lesions, which may include cysts, fibroadenomas, benign or malignant tumors, aberrant breast tissue, duct lesions, or nipple/areolar lesions. This procedure is performed on either male or female patients and encompasses the removal of one or multiple lesions through an open incision. The primary objective of this procedure is to completely remove the targeted palpable or non-palpable mass for definitive diagnostic pathology and therapeutic purposes. Before the procedure, the patient is prepped and draped in a sterile fashion, and local, regional, or general anesthesia is administered depending on the patient's condition and the surgeon's preference. The surgeon makes an incision in the breast, carefully planned to achieve optimal cosmetic results, often using a periareolar or circumareolar approach, or an incision directly over the palpable mass following the skin tension lines. The underlying subcutaneous tissue is dissected to expose the breast mass. The surgeon then carefully excises the entire cyst, fibroadenoma, or tumor, ensuring appropriate margins if malignancy is suspected or as dictated by the pre-operative plan. Care is taken to preserve as much normal surrounding breast tissue as possible. Once the lesion is completely removed, it is typically sent to pathology for comprehensive histological evaluation. The surgical site is then copiously irrigated, and meticulous hemostasis is achieved using electrocautery or ligatures. The deep breast tissue may be approximated to prevent dead space and fluid accumulation. Finally, the skin is closed in layers using absorbable sutures, and sterile dressings are applied. This code is distinct from percutaneous needle biopsies and encompasses the total open removal of the specific lesion.

Clinical Indications

  • Palpable breast mass suspected to be a fibroadenoma.
  • Complex or symptomatic breast cysts unresponsive to aspiration.
  • Aberrant or ectopic breast tissue causing discomfort or cosmetic concern.
  • Suspicious ductal lesions presenting with pathological nipple discharge.
  • Benign or malignant tumors requiring complete surgical excision for diagnosis and treatment.
  • Nipple or areolar lesions requiring open removal.

Procedure Steps

  1. The patient is placed in a supine position and the breast is prepped and draped in a sterile fashion.
  2. Local, regional, or general anesthesia is administered.
  3. An incision is made over the palpable mass or in a cosmetically favorable location (e.g., periareolar).
  4. Sharp and blunt dissection is used to navigate through the subcutaneous tissue to the breast parenchyma.
  5. The targeted cyst, fibroadenoma, or tumor is identified and carefully dissected free from the surrounding normal breast tissue.
  6. The lesion is completely excised and passed off the sterile field for pathological examination.
  7. The surgical cavity is irrigated, and rigorous hemostasis is obtained using electrocautery.
  8. The surgical cavity may be re-approximated with deep sutures to eliminate dead space.
  9. The skin is closed in layers, typically utilizing subcuticular absorbable sutures, and a sterile dressing is applied.

Coding Guidelines

  • Report 19120 only once per breast, regardless of the number of lesions excised from that breast through the same or different incisions.
  • Do not report 19120 in conjunction with percutaneous biopsy codes (e.g., 19081-19086) for the same lesion.
  • If bilateral excisions are performed, use modifier 50.
  • This code does not include mastectomy for gynecomastia (report 19300).
  • If wire localization is used, the placement of the wire is reported separately by the radiologist, but the excision should be coded with 19125/19126 instead of 19120.

Associated ICD-10 Codes