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Download Side Matters!! - Contempo Coding
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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 documented! ◦ Right or left ◦ Mirror procedure on both sides ◦ Determine payer preference of modifers Cosmetics 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 Reconstruction 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. http://www.hopkinsmedicine.org/ 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 code. Example 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 19357-59 Latissimus Dorsi Flap Pedicled Transverse Rectus Abdominus Myocutaneous Flap CPT 19367 for single pedicle CPT 19368 for single pedicle with supercharging 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 trunk. 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 Flap Transverse Upper Gracilis (TUG) Flap Gluteal Artery Perforator (GAP) Flap 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. Revisions 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. Revisions Dog ear excisions generally code to adjacent tissue transfer codes. Scar revision use complex repair codes 1310X. Revisions 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 ICD9 ICD10 Description 174.9 C5Ø.919 Malignant neoplasm of breast 198.81 C79.81 233.0 DØ5.9Ø Carcinoma in situ of breast V10.3 Z85.3 Personal history of malignant neoplasm of breast V16.3 Z8Ø.3 Family history of malignant neoplasm of breast V45.71 Z9Ø.1Ø Acquired absence of breast and nipple V51.0 Z42.1 Encounter for breast reconstruction following mastectomy V84.01 Z15.Ø1 Genetic susceptibility to malignant neoplasm of breast Secondary malignant neoplasm of breast Questions? A copy of this presentation will be available at contempocoding.com Questions, comments, feedback e-mail [email protected].
