02-10-2023 CoC Continues Field Study of 4 Breast Surgery Codes 2022-2023
The CoC is continuing this field study for updating the surgery codes in Appendix A, to support the Synoptic Operative Reporting and to allow for more descriptive surgery codes. This data item can be used to compare the efficacy of treatment options. Please refer to the STORE 2023 for information on how to code these fields page 219-228. The codes are VERY SPECIFIC, you will need to review all the codes to pick the most appropriate value. STORE 2023 https://www.facs.org/quality-programs/cancer/ncdb/call-for-data
Scenario: + FNA followed by lumpectomy done elsewhere:
- 01-01-2023 Bx RUOQ at my facility: Invasive Ductal Ca ER 90% positive strong intensity, PR 98% positive strong intensity, Her2 1+ negative
- 01-15-2023 Lumpectomy & Sentinel Lymph Node Biopsy done elsewhere: Invasive Ductal Ca 1.2cm Grade 2, 2 SLN (-), LVI (-), Margins (-)
| Field | Code | Definition | Coding Source/Discussion |
| Rx Summ-Surg 2023 | A220 | Lumpectomy or excisional bx | STORE 2023 APPENDIX A: Site-Specific Surgery Codes [Note Surgery fields in 2023 are 4-digit Alpha-Numeric codes] |
| Rx Hosp-Surg 2023 | A000 | None; no surgery of primary site | It would be 00 because no surgery done at this facility [Often auto filled by registry software] [Note Surgery fields in 2023 are 4-digit Alpha-Numeric codes] |
| Rx Summ-Surg Breast | B200 | Partial mastectomy; less than total mastectomy; lumpectomy, segmental mastectomy, quadrantectomy, tylectomy, with or without nipple resection | STORE 2023 page 222-224 |
| Rx Hosp-Surg Breast | B000 | None; no surgery of primary site | STORE 2023 page 219-221 [It would be B000 because no surgery done at this facility] |
| Rx Sum-Recon Breast | A000 | No Reconstruction NOTE: Code A000 when no immediate reconstruction was performed at any facility. | STORE 2023 page 227-228 |
| Rx Hosp-Recon Breast | A000 | No Reconstruction NOTE: Code A000 when no immediate reconstruction was performed at any facility. | STORE 2023 page 225-226 |
Scenario: FNA showed atypical hyperplasia followed by lumpectomy done elsewhere:
- 01-01-2023 Diagnosed on Mammogram at my facility BIRAD 5 RUOQ-suspicious for malignancy
- 01-01-2023 Bx RUOQ at my facility-atypical ductal hyperplasia
- 01-15-2023 Lumpectomy & Sentinel Lymph Node Biopsy done elsewhere: Invasive Ductal Ca 1.2cm Grade 2, 2 SLN (-), LVI (-), Margins (-)
| Field | Code | Definition | Coding Source/Discussion |
| Rx Summ-Surg 2023 | A220 | Lumpectomy or excisional bx | STORE 2023APPENDIX A: Site-Specific Surgery Codes [Note Surgery fields in 2023 are 4-digit Alpha-Numeric codes] |
| Rx Hosp-Surg 2023 | A000 | None; no surgery of primary site | It would be 00 because no surgery done at this facility [Often auto filled by registry software] [Note Surgery fields in 2023 are 4-digit Alpha-Numeric codes] |
| Rx Summ-Surg Breast | B215 | Excisional breast biopsy, for atypia NOTE: An excisional breast biopsy removes the entire tumor and/or leave only microscopic margins. This surgical code was added to collect code when atypia tissue is excised and found to be reportable. Approx. 10-15% of excised atypia are cancer and reportable. Example: Use code B215 when patient has biopsy that shows atypical ductal hyperplasia, an excision is then performed, and pathology shows in situ or invasive cancer. The excisional breast biopsy for the ADH diagnosed the cancer, not the core biopsy | STORE 2023 page 222-224 |
| Rx Hosp-Surg Breast | B000 | None; no surgery of primary site | STORE 2023 page 219-221 [It would be B000 because no surgery done at this facility] |
| Rx Sum-Recon Breast | A000 | No Reconstruction NOTE: Code A000 when no immediate reconstruction was performed at any facility. | STORE 2023 page 227-228 |
| Rx Hosp-Recon Breast | A000 | No Reconstruction NOTE: Code A000 when no immediate reconstruction was performed at any facility. | STORE 2023 page 225-226 |
Scenario: + FNA followed by Skin Sparing Mastectomy without removal of uninvolved contralateral breast + tissue expander done at my facility
01-01-2023 Bx RUOQ at my facility: Invasive Ductal Ca ER 90% positive strong intensity, PR 98% positive strong intensity, Her2 1+ negative
01-15-2023 Skin Sparing Mastectomy without removal of uninvolved contralateral breast + reconstruction with tissue expander placement done at my facility: Invasive Ductal Ca 1.2cm Grade 2, 2 SLN (-), LVI (-), Margins (-)
04-15-2023 Implant placed
| Field | Code | Definition | Coding Source/Discussion |
| Rx Summ-Surg 2023 | A450 | Total (simple) mastectomy WITHOUT removal of uninvolved contralateral breast with Implant reconstruction | STORE 2023 APPENDIX A: Site-Specific Surgery Codes [Note Surgery fields in 2023 are 4-digit Alpha-Numeric codes] |
| Rx Hosp-Surg 2023 | A450 | Total (simple) mastectomy WITHOUT removal of uninvolved contralateral breast with Implant reconstruction | [Often auto filled by registry software] [Note Surgery fields in 2023 are 4-digit Alpha-Numeric codes] |
| Rx Summ-Surg Breast | B310 | Skin-sparing mastectomy WITHOUT removal of uninvolved contralateral breast NOTE: A skin sparing mastectomy removes all breast tissue and the nipple areolar complex and preserves native breast skin to cover the immediate reconstruction. It is performed with and without sentinel node biopsy or ALND. | STORE 2023 page 222-224 |
| Rx Hosp-Surg Breast | B310 | Skin-sparing mastectomy WITHOUT removal of uninvolved contralateral breast | STORE 2023 page 219-221 |
| Rx Sum-Recon Breast | A100 | Tissue expander placement NOTE: Code A100 when tissue expanders were placed without implant or tissue placement. | STORE 2023 page 227-228 |
| Rx Hosp-Recon Breast | A100 | Tissue expander placement | STORE 2023 page 225-226 |
Rx Hosp Surg Breast & Rx Summ Surg Breast Codes 2022-2023
Rx Hosp-Recon Breast & Rx Sum-Recon Breast Codes
