Revenue Cycle Insider

Hint: Look to the C50.- series for most diagnoses.

While mastectomy coding may be relatively straightforward in some instances, it can be among the more challenging surgeries to code in other situations. The key to collecting appropriate reimbursement is to first identify which type of mastectomy the surgeon performed. And since the provider may not always use the terms you’ll find in the CPT^® code book, the surgical approach can sometimes be difficult to pinpoint.

Read on for tips on coding mastectomies so you can collect for these complex surgeries.

Differentiate the Mastectomy Types

While you’ll find quite a few mastectomy types in the CPT^® code book, these are the three main types that you’re likely to encounter:

• Partial mastectomy: This typically refers to excision of a breast mass, which the surgeon removes along with an additional margin of healthy tissue. To report this, you’ll usually report 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)). As noted in the descriptor, other terms that may be used for this procedure include segmentectomy, lumpectomy, tylectomy, or quadrantectomy.

If the surgeon performs sentinel node excision or removes other axillary lymph nodes along with the partial mastectomy, report 19302 (… with axillary lymphadenectomy) instead of 19301.

• Simple complete mastectomy: In situations where the surgeon excises all of the patient’s breast tissue, you’ll report 19303 (Mastectomy, simple, complete). This code typically covers the removal of the entire breast, which includes the nipple, areola, lymph nodes, and all breast tissue. The surgeon may refer to this as a total mastectomy.

Keep in mind that the surgeon may preserve the nipple in some cases. For many payers, this is still reported with 19303 since the surgical maneuver isn’t different whether the nipple is spared or not, the American College of Surgeons advises. However, each payer may have different coverage guidelines for how to report a nipple-sparing mastectomy, so always confirm how to report this with your individual payer.

• Radical mastectomy: If the surgeon removes all of the patient’s breast tissue, skin, nipple, areola, axillary lymph nodes, and the underlying chest muscles, that’s considered a radical mastectomy. For this procedure, you’ll report 19305 (Mastectomy, radical, including pectoral muscles, axillary lymph nodes).

In some cases, during a radical mastectomy, the surgeon will perform what’s known as an Urban procedure. This involves removing all of the tissue involved in the radical mastectomy, as well as the axillary lymph nodes and the internal mammary lymph nodes. You’ll report 19306 (Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)) for this service.

Look to the C50.- Series for Diagnosis Codes

To demonstrate medical necessity for your mastectomy procedures, be sure to report the most accurate diagnosis codes.

The majority of mastectomies are performed for breast cancers, which fall under the C50.- (Malignant neoplasm of breast) code series. The 4^th characters used in the C50.- codes provide details about the cancer’s specifics, such as where the cancer is located.

For instance, C50.4- (Malignant neoplasm of upper-outer quadrant of breast) describes breast cancer in the upper outer quadrant, which is the most common location for breast cancers.

The provider’s documentation should be extremely clear about where in the breast the cancer is located. If your provider doesn’t include these details in the patient’s record, you will need to ask for more information before selecting the appropriate code.

Prophylactic mastectomy: In cases where patients are getting a prophylactic mastectomy due to being at high risk for developing breast cancer, you should not report a breast cancer diagnosis code, since the patient has not been definitively diagnosed with cancer. Several diagnosis codes may be payable for prophylactic mastectomies depending on your payer, but Z40.01 (Encounter for prophylactic removal of breast) is the most commonly reported code.

Check Payer Policies When Coding Reconstructions

The surgeon may perform breast reconstruction at the same surgical session as the mastectomy, or they may instead opt to perform reconstruction at a later date. Your payer may have specific policies about which reconstruction methods are payable, either on the date of service when the mastectomy occurred or thereafter.

The codes may differ depending on when the reconstruction procedure takes place. For instance, if the surgeon performs breast implantation during the same surgical session as the mastectomy, you’ll report 19340 (Insertion of breast implant on same day of mastectomy (ie, immediate)). If, however, the surgeon performs breast implantation at a later date, you’ll report 19342 (Insertion or replacement of breast implant on separate day from mastectomy).

For delayed reconstructions, as described by 19342, the surgeon may insert a tissue expander following the mastectomy procedure. For this service, you’ll report 19357 (Tissue expander placement in breast reconstruction, including subsequent expansion(s)). The tissue expander helps create a space that will later accommodate an implant. Over time, the provider will inject saline into the expander to help the surrounding skin grow to make room for the implant.

Code 19342 includes payment for all subsequent expansions, not just those that occur within the global surgical period of the mastectomy. For that reason, you should not report additional codes for the expansions, even following the 90 days post-mastectomy.

Torrey Kim, Contributing Writer, Raleigh, NC