Mastectomy and Breast Reconstruction Codes
Focus on the details in your physician’s op report to get past imprecise terminology.
By Suzan Hvizdash, CPC, CPC-EMS, CPC-EDS
The complexities of coding mastectomy and reconstruction seem to parallel the complexities of the surgery itself. A simple mastectomy may be simple to code. More complicated cases may take some analysis and interpretation of coding rules.
For example, in advanced tumors, the volume of tissue removed sometimes precludes simple closure. In patients who will be undergoing radiation therapy to treat malignancy, flaps or grafts are delayed until after the radiation is completed because the radiation can negatively impact the success of the graft. How does the coder reflect the incomplete surgical package (sans closure of the surgical wound)?
The answers aren’t straightforward and must be taken on a case by case basis. In the case of a patient who is undergoing mastectomy for a large friable and vascular tumor (e.g., cystosarcoma phyllodes), the loss of an unusual amount of blood may require multiple units of blood transfused. It may be that the coder would weigh the added complexity of the procedure, as reported with modifier 22, against the reduced service of no wound closure, as reported with modifier 52, and report no modifiers with the procedure.
While there are no rules or guidelines to govern these instances, an expert coder can come up with an answer and take it to the payer. Results will vary. Payers also will vary on policies on paying for secondary closure outside the global period, but documentation can be submitted to show that this service was not unbundled from the original surgery.
The secret to accurately code is to not get hung up on terminology. Imprecise terms such as “lumpectomy” in documentation will only cause confusion. Instead, encourage physicians to document the specifics of lesion size, width of surgical margins and total area of tissue removed, as well as the location and type of donor tissue for reconstructions. Coders focusing on these details will find the answers. If surgical margins are not addressed specifically, then an excision/biopsy code would be reported instead of a mastectomy code.
The CPT® codebook describes four types of mastectomies:
- Partial mastectomy
- Simple complete mastectomy
- Subcutaneous mastectomy
- Radical mastectomy
For female patients, partial mastectomy involves excising the mass from the breast, taking along with it a margin of healthy tissue. The title of the procedure will be important when determining the physician’s intention for the procedure. The surgeon may also refer to a partial mastectomy as a lumpectomy, quadrantectomy or segmentectomy, although these are imprecise terms that could be applied to any breast excision. Code 19301 should be used for these partial mastectomies. If the physician also performed sentinel node or other axillary node excision, report 19302. Remember that sentinel node injection is separately reported with 38792.
If the surgeon removes all (rather than just a portion) of the breast tissue, report a simple total mastectomy using 19303. Generally, the surgeon will attempt to remove as little skin as possible, but some skin is inevitably removed along with the nipple. This is done through an elliptical incision. During a subcutaneous mastectomy (19304), the surgeon dissects the breast away from the pectoral fascia and skin. As with the simple complete mastectomy, the surgeon removes all of the breast tissue, but spares the skin and pectoral fascia. The documentation should clearly illustrate the more complex nature of this procedure.
A radical mastectomy occurs when the surgeon removes the complete breast, the skin, the pectoralis major muscle, pectoralis minor muscle and the axillary lymph nodes at the same time. The code for this type of more involved mastectomy is 19305.
When both axillary lymph nodes and the internal mammary lymph nodes are taken during this operative session, the pectoralis major and minor can be spared. If the physician performs this procedure (also known as the Urban-type mastectomy), report 19306.
While some excisions may be performed for benign conditions, most mastectomies are performed for malignancy. About two-thirds of breast cancers require estrogen to thrive, and can therefore be managed with estrogen-blocking drugs. These drugs reduce the chance of the cancer recurring and improve survival rates. ICD-9-CM implemented new codes in 2007 to report estrogen receptiveness of breast cancer. Report V86.0 for a positive status, seen in medical records as ER+, or V86.1 for no estrogen receptors (ER-).
Coding Issues With Reconstructions
Reconstruction following excision brings important considerations for both the patient and surgeon. Is this performed at the time of the mastectomy? Is tissue from one area being attached to the chest wall to form an aesthetically appearing breast? Is the tissue left in the area given ample opportunity to grow, making room for an implant down the road? As with any surgery, there are risks to the reconstruction procedures, including the potential removal of the implanted prosthetic if a complication occurs. The size of the breast and the defect may also be factors in deciding which reconstruction method is best for the patient. The government passed the Women’s Health and Cancer Act (WHCRA) of 1998, enforcing coverage of reconstruction following mastectomies (if the plan allows for mastectomies). Check with your state’s Department of Insurance for your state’s coverage requirements.
There are many different options for the reconstruction that include breast prosthesis insertions, breast reconstruction, tissue expansion, latissimus dorsi flap reconstruction, TRAM procedures and free flap breast reconstruction.
Breast implants are, perhaps, the most well-known reconstruction methods. These can be done during the same surgical session as the mastectomy (19340) or at a later time (19342). If reconstruction is delayed, the surgeon may perform a tissue expansion (19357). The surgeon may insert the expander permanently, or he might place it temporarily to create a space in the chest wall muscle to accommodate an implant in the future. Saline is injected (through a port) at periodic intervals to help the surrounding skin grow. This is usually done when a lot of breast tissue was removed and the goal is to match the size of the other breast. Note that this procedure includes ALL subsequent expansions and not just those done within the first 90 days postoperatively. If, during a subsequent visit for tissue expansion, the physician provides a separately identifiable E/M service, you may report the E/M separately, but documentation should substantiate that the visit involved a service unrelated to the tissue expansion.
Three additional reconstruction procedures include transferring skin from another part of the patient’s body to the breast area. The latissimus dorsi flap (19361) describes a procedure during which muscle and skin are taken from the patient’s back and used to reconstruct a breast. The tissue is attached to the chest wall and surrounding muscles to allow for a complete and more natural appearance.
TRAM reconstruction involves using the skin and muscles from the abdomen to create a breast. The advantage to this technique is that the tissue remains attached to its blood supply. For a single pedicle flap, report 19367. If the surgeon uses two pedicles of the rectus abdominis, report 19369. When the flaps are performed with microvascular anastomsis for the connection of additional blood vessels, you should call on 19368. Note that these codes include closure of the donor site.
Lastly, a free flap reconstruction (19364) occurs when skin, fat and muscle from any other area of the patient are taken to construct an aesthetically pleasing breast. The tissue used most often is from the buttocks or thighs of the patient.
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