Partial Mastectomy (Lumpectomy)
[Right / Left] breast [ductal carcinoma in situ / invasive ductal carcinoma / invasive lobular carcinoma]
Same
[Right / Left] partial mastectomy (lumpectomy) with [wire / magnetic seed / radar reflector / radioactive seed] localization
[***, MD/DO]
[Resident/PA name]
[General anesthesia via laryngeal mask airway / Monitored anesthesia care with local anesthesia]
The patient is a [age]-year-old [female / male] with biopsy-proven [right / left] breast [ductal carcinoma in situ / invasive carcinoma] [measuring [X cm] on imaging], presenting for breast-conserving surgery. Image-guided localization of the [lesion / biopsy clip] was performed preoperatively. The risks, benefits, and alternatives, including mastectomy, were discussed, and informed consent was obtained.
The localized lesion was excised from the [clock position] position of the [right / left] breast. Specimen radiograph confirmed the [lesion, biopsy clip, and localizer / biopsy clip and localizer] within the specimen.
The patient was brought to the operating room and placed supine with the ipsilateral arm abducted on an arm board. [General anesthesia was induced / Monitored anesthesia care was initiated, and local anesthetic was infiltrated]. A surgical timeout was performed confirming patient identity, procedure, operative site and laterality, allergies, and administration of prophylactic antibiotics. The breast was prepped and draped in sterile fashion.
A [curvilinear / radial / periareolar] incision was made overlying the localized lesion. Guided by the localizer, the lesion was excised with a rim of grossly normal breast tissue[, carrying the dissection to the pectoralis fascia]. The specimen was oriented with a short suture marking the superior margin and a long suture marking the lateral margin. Specimen radiograph confirmed the [lesion, biopsy clip, and localizer / biopsy clip and localizer] within the specimen. [Additional cavity shave margins were excised from the [superior, inferior, medial, and lateral] walls, each marked on the new margin surface and sent separately.]
The cavity was irrigated, and hemostasis was achieved with electrocautery. [Titanium clips were placed in the cavity walls for radiation planning.] [Oncoplastic tissue rearrangement was performed by mobilizing the adjacent breast parenchyma and reapproximating it with [2-0 Vicryl] sutures to fill the defect.] The incision was closed in layers with [3-0 Vicryl] deep dermal and [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
[Right / Left] partial mastectomy specimen, oriented (short suture superior, long suture lateral)[; separate cavity shave margins, labeled by orientation]
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** breast ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** partial mastectomy (lumpectomy) with *** localization
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with biopsy-proven *** breast *** measuring *** cm on imaging, presenting for breast-conserving surgery. Image-guided localization was performed preoperatively. The risks, benefits, and alternatives, including mastectomy, were discussed, and informed consent was obtained.
FINDINGS: The localized lesion was excised from the *** position of the *** breast. Specimen radiograph confirmed the *** and localizer within the specimen.
DESCRIPTION OF PROCEDURE:
Supine, arm abducted. *** anesthesia. Surgical timeout performed; laterality confirmed. Breast prepped and draped.
*** incision over the localized lesion. Lesion excised with a rim of normal breast tissue under localizer guidance. Specimen oriented (short suture superior, long suture lateral). Specimen radiograph confirmed the *** and localizer. [*** cavity shave margins excised and sent separately.] [Titanium clips placed in the cavity for radiation planning.] Hemostasis. Closure with 3-0 Vicryl deep dermal and 4-0 Monocryl subcuticular sutures.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Partial mastectomy specimen (oriented) and *** cavity shave margins to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Excisional Biopsy: Palpable Mass
The [X cm] mass in the [clock position] position of the [right / left] breast was palpable, and no preoperative localization was performed. [Intraoperative ultrasound was used to confirm the lesion location.] A [curvilinear / radial / periareolar] incision was made over the mass, placed to fall within a future lumpectomy or mastectomy incision. The mass was excised intact with a rim of normal breast tissue. The specimen was oriented with a short suture marking the superior margin and a long suture marking the lateral margin and sent to pathology. Hemostasis was achieved with electrocautery, and the incision was closed in layers with [3-0 Vicryl] deep dermal and [4-0 Monocryl] subcuticular sutures.
Margin Re-excision
Re-excision was performed for a [positive / close] [location] margin on final pathology from the partial mastectomy of [date]. The prior incision was opened, and the seroma cavity was entered and evacuated. The [location] cavity wall was excised as a new margin[, including the [overlying skin / underlying pectoralis fascia]], and the new final margin surface was marked with a suture. [Additional shave margins were excised from the [location] walls and sent separately.] [Titanium clips were placed in the cavity walls for radiation planning.] Hemostasis was achieved with electrocautery, and the incision was closed in layers with [3-0 Vicryl] deep dermal and [4-0 Monocryl] subcuticular sutures.
Charting Tips
- State the orientation convention (for example, short suture superior, long suture lateral) and label each cavity shave by its orientation. This allows a targeted re-excision of a single margin if final pathology is positive.
- Document that the specimen radiograph showed the target lesion or biopsy clip and the localizer. If a seed or reflector is not seen on the radiograph, document its retrieval from the cavity. Radioactive seeds also need chain-of-custody documentation per institutional radiation-safety policy.
- Document cavity clip placement. Clips mark the tumor bed for radiation boost and partial-breast planning and for future imaging.
- For re-excision, name the involved margin and the pathology report it came from, and mark the new final margin so pathology can assess it directly.
Documentation & Reimbursement Considerations
- Primary service: Report Partial Mastectomy (Lumpectomy) as the primary service when it is the definitive operation performed.
- The partial mastectomy code (9.88 wRVU, 90-day global) applies to excision of a known malignancy or other lesion with attention to margins. Cavity shave margins and oncoplastic tissue rearrangement at the same operation are included and do not change the code.
- Excisional biopsy of an undiagnosed mass without margin intent uses the breast lesion excision code (5.77 wRVU, 90-day global), or the localized lesion excision code (6.52 wRVU, 90-day global) when a preoperatively placed localizer guides the excision. Do not bill these with the partial mastectomy code for the same lesion.
- Margin re-excision within the global period is reported with the partial mastectomy code and the staged-procedure modifier, which starts a new 90-day global period. Document the positive or close margin from the prior pathology report.
- 90-day global period: wound checks and surgical follow-up are bundled. Radiation oncology and medical oncology bill independently.