When coding a breast repair or reconstruction procedure, there are a few key documentation terms to keep in mind that will help determine the most accurate code for reimbursement.
Mammoplasty is a surgical modification or repair of a breast. When an augmentation is performed, ascertain if a prosthetic implant was used in this repair. If so, code 19325 Mammoplasty, augmentation; with prosthetic implant is reported. If not, code 19324 Mammoplasty, augmentation; without prosthetic implant is more accurate.
Reconstruction procedures rebuild the breast. The three components of the process may occur all in one session or over several encounters.
1. Breast reconstruction procedures use a specific type of expander or flap described by the code reported.
A saline-filled tissue expander (19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion) is used, after a mastectomy, to stretch surrounding skin in preparation for a prosthetic implant to be inserted at a later date.
Flaps surgically build up skin to support or create the new breast. The specific type of flap will direct you to a correct code.
Latissimus dorsi flap (19361 Breast reconstruction with latissimus dorsi flap, without prosthetic implant) tissue is tunneled from the patient’s back (the latissimus dorsi — below the shoulder blade) and positioned into a mound to support a reconstructed breast.
Free flap (19364 Breast reconstruction with free flap) techniques use tissue transplanted from the patient’s thighs or buttocks to support or create the new breast. Blood vessels within the transplanted tissue are connected to those in the chest to maintain a blood supply (called anastomosis). This procedure typically requires a surgeon with both plastic surgery and microvascular surgical skills. A free flap takes longer than a pedicle flap but is believed to create a more naturally-shaped breast.
A transverse rectus abdominis myocutaneous flap (TRAM) (19367, 19368, 19369, Breast reconstruction with transverse rectus abdominus myocutaneous flap [TRAM], single pedicle, including closure of donor site...) transplants muscle, fat, and skin from the patient’s abdominal area tunneled to form the new breast mound. TRAM may be done using a pedicle flap or a free flap technique and requires additional procedures to create an areola and nipple.
Should the surgeon document some other technique (19366 Breast reconstruction with other technique), it is a wise to include a copy of the operative notes to support the use of this code.
2. The insertion of the prosthesis is the next stage of breast reconstruction and is generally reported with a code additional to the reconstructive surgery code. To choose the correct code, the documentation will need to indicate whether this was performed immediately after a mastectomy, mastopexy or reconstructive procedure (19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction) or done at a later session (19342 Delayed insertion for breast prosthesis following mastopexy, mastectomy or in reconstruction).
3. The last portion of the reconstructive process is the actual prosthesis — the implant that is set in to the reconstructed breast. To code this properly you will need to know if the patient’s insurance carrier accepts HCPCS Level II codes. If so, consider L8600 Implantable breast prosthesis, silicone or equal. If not, CPT code 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or material provided) may be used, with an attached report to explain the details. Always report the implant concurrent to the implant procedure (step 2).
Note: CPT codes (19316-19396) report a unilateral procedure. When a bilateral procedure is performed, append modifier 50 Bilateral procedure to the correct code.
Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, is president of Safian Communications Services Inc., a healthcare revenue management consulting firm. She teaches health information management/coding and is the author of several books on this subject. Shelley is also a member of the American Academy of Professional Coders (AAPC; aapc.com), the nation’s largest education and credentialing association for medical coders.