Side Matters!! - Contempo Coding

Breast Reconstruction Coding
Victoria M. Moll, CPC, CPMA, CPRC
Contempo Coding cannot guarantee reimbursement for services as an outcome of the information and/or data
used and disclaims any responsibility for denial of reimbursement. This information is intended for informational
purposes only. Current Procedural Terminology (CPT©) is copyright and trademark of the 2012 American
Medical Association (AMA). Don’t bother suing me -- I have no money.
Side Matters!!
With all breast coding, all CPT codes are
UNIlateral, so side must be properly
◦ Right or left
◦ Mirror procedure on both sides
◦ Determine payer preference of modifers
Two most common cosmetic procedures
are breast lift and breast augmentation
with implant.
 Can be done alone or together.
Mastopexy = 19316
Mammoplasty augmentation = 19325
ICD9 = V50.1 Cosmetic surgery
ICD10 = Z41.1 Cosmetic surgery
Most reconstructions are done
immediately following a mastectomy.
Reconstruction can be autologous (using
the patient’s own tissue) or implants can
be utilized.
Tissue Expanders
Most common post-mastectomy
reconstruction method
Done in stages, so watch for modifier 58
for procedures done in the global period
◦ Stage 1 = Insertion of expander
◦ Stage 2 = Exchange of expander for implant
◦ Stage 3 = Nipple reconstruction
Tissue Expanders
First stage is insertion of the tissue
expander into the chest wall CPT 19357.
Tissue Expanders
During insertion, saline is partially filled in
the expander.
 The patient presents to the office for
subsequent fills of saline via a port.
 All fills within the 90-day global are
included in the code for the tissue
expander insertions.
 Fills done after the 90-day global period
has expired can be billed with the
appropriate evaluation and management
Patient has a tissue expander placed on
1/10/14. She presents to the office every
few weeks for fills. At the time of her
4/20/14 fill, she is no longer in her 90-day
global period. During this visit a problem
focused history, problem focused exam,
and a straightforward medical decision
making is completed.
CPT code 99212.
Expander Exchange
Basic expander exchange with minor
adjustments to capsule use CPT code
11970 Replacement of tissue expander with
permanent prosthesis.
 Expander exchange with considerable
capsule work, capsulectomy, and/or
adjustment to the infra-mammory crease
is coded to 19342 per AMA’s January
2013 CPT Assist.
Expander Exchange – Example 1
The physician came down upon the
previous scar and excised it as an ellipse.
He came down to the expander, which was
easily peeled off and removed. The pocket
was washed with sterile saline, a silicone
implant was placed, and the wound was
sutured in layers.
CPT 11970 – Replacement of tissue
expander(s) with permanent prosthesis.
Expander Exchange – Example 2
The physician incises the previous scar, removes it and
passes it off the field. Bovie is used to deepen down to
the capsule. The capsule was particularly thick, dense,
and tight. Several radical incisions were made and a
complete capsulectomy was performed. The expander
was removed, the pocket washed with sterile saline, and
an implant was deployed. Wound was sutured close.
CPT 19342 – Delayed insertion of breast prosethesis
following mastopexy, mastectomy, or in reconstruction.
(Used to represent the extended exchange service)
Nipple reconstruction
CPT 19350 is for reconstruction of the
nipple/areola. Any flaps/grafts used to
create a nipple are included in this code.
It also includes tattooing within the 90day global period.
Nipple tattooing OUTSIDE the 90-day
global period is billable with the nipple
tattooing codes 11921 & 11922
Nipple reconstruction
Example 1 – Patient has a nipple
reconstruction with skate flap. This is
coded as a 19350. Three weeks later the
patient presents to the office for
tattooing of the nipple.
The tattooing is considered part of
completing a nipple reconstruction, as is
included in the reimbursement for 19350.
The tattooing is not separately billable.
Nipple reconstruction
Example 2 – Patient presents to the office
3 years after her reconstruction and has
fading of her nipple tattoos. The physician
performs a touch-up of the tattoos, each
of which is 10 square centimeters. (20 sq
cm total)
CPT Code
11921 – Tattooing, 6.1 to 20.0 sq cm
Alloderm placement
15777 is used for the
placement of a dermal
matrix for soft tissue
reinforcement of the
trunk or breast. It can
aid in allowing a larger
implant to be placed
into the chest wall.
Autologous reconstruction
Codes for autologous reconstruction
span CPT 19361 – 19369.
If an implant is placed in addition to the
autologous reconstruction, add CPT
19340 for immediate insertion of a breast
prosthesis following mastopexy,
mastectomy, or in reconstruction.
Latissimus Dorsi Flap
CPT Code 19361 is Latissimus Dorsi Flap
is done without implant
If an implant is placed, add CPT 19340.
If a tissue expander is placed, add CPT
Latissimus Dorsi Flap
Pedicled Transverse Rectus
Abdominus Myocutaneous Flap
CPT 19367 for single pedicle
CPT 19368 for single pedicle with
 CPT 19369 for double pedicle
If TRAM is being done in a delayed, staged
fashion, use 15600 – delay of flap or
sectioning of flap (division and inset); at
Pedicled Transverse Rectus
Abdominus Myocutaneous Flap
Free Flaps
All breast free flaps are coded to CPT 19364, although the
DIEP may be coded to 19364-22 or S2068 for some carriers.
Determine payer preference when authorizing.
19364 includes harvesting of the flap, microvascular transfer,
closure of the donor site, and inset shaping the flap into a
breast. Vein grafting can be separately billed.
Perforator free flaps (DIEP, SIEP) require a surgeon specially
trained in microvascular surgery.
Free Transverse Rectus Abdominus
Myocutaneous Flap
Superficial Inferior Epigastric
Artery Flap
Deep Inferior Epigastric Perforator
Transverse Upper Gracilis (TUG)
Gluteal Artery Perforator (GAP)
Other reconstructions
If breast tissue is simply re-arranged to
reconstruct a defect, use CPT 19366.
Ryan Flaps code to the adjacent tissue
transfers CPT 14001-14302
Use 19120 for 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, one or more lesions.
CPT 19380, Revision of a previously reconstructed
breast can ONLY be used AFTER a breast has
completed reconstruction, and not during (ie, at a
tissue expander exchange). Some procedures include:
◦ Rearrangement to achieve symmetry
◦ Liposuction to achieve symmetry / shaping
◦ Repositioning of a flap (TRAM, LD, etc)
◦ Adjustments of the inframmory crease
For complications in the 90-day global, use modifier
78. For a planned revision, use modifier 58.
Dog ear excisions
generally code to
adjacent tissue
transfer codes.
Scar revision use
complex repair codes
Capsulectomy includes a removal of an
implant, but you can code separately for
insertion of a new one.
◦ Capsulectomy = 19371
◦ Insertion = 19340
Removal of intact implant and exchange
for new implant.
◦ CPT 19340
Removal of ruptured implant and
exchange for new implant.
◦ CPT 19328, 19330-51
Breast Cancer Diagnosis
For breast cancer patient, many payers
will only pay claims if breast cancer
(174.9) or history of breast cancer
(V10.3) is used as the PRIMARY diagnosis.
Be sure that documentation by providers
supports these diagnoses. If it does not,
request an addenda.
Remember – an operative report is a
stand-alone document.You can only code
what is in the report!
Commonly Used Diagnoses
C5Ø.919 Malignant neoplasm of breast
DØ5.9Ø Carcinoma in situ of breast
Personal history of malignant neoplasm of breast
Family history of malignant neoplasm of breast
Z9Ø.1Ø Acquired absence of breast and nipple
Encounter for breast reconstruction following mastectomy
Genetic susceptibility to malignant neoplasm of breast
Secondary malignant neoplasm of breast
A copy of this presentation will be
available at
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