General Surgery Coding Alert

Question: A patient has cancer in one breast and needs a modified radical mastectomy. Because there is also a family history for breast cancer, the surgeon recommends and the patient agrees to have her benign breast removed. What diagnosis do you use for the simple mastectomy of the benign breast?

Montana Subscriber

Answer: The primary diagnosis for the removal of the healthy breast should be V50.41 (prophylactic organ removal, breast), says Elaine Elliott, CPC, lead practice coder with Treasure Coast Surgical Group in Stuart, Fla. The patients personal history of breast cancer (V10.3) should be included as a secondary code, Elliott adds, noting that once the patient is diagnosed with breast cancer, her family history of breast cancer no longer needs to be included.

It is not an unusual occurrence for a breast-cancer patient to request the removal of a healthy breast. The patient may be terrified of regular visits to the surgeon for breast biopsies, and conclude that she will regain peace of mind only when the other breast is gone. The surgeon should document the patients fear, Elliott says, and refrain from using psychological codes to justify the procedure when it is performed because some carriers may reduce a procedure that is justified mainly on psychological grounds.

ICD-9 codes 174.x (malignant neoplasm of female breast) should not be used to justify removal of the healthy breast. Even though the patient does have a neoplasm, using this code for the healthy side of the body could be considered fraudulent in the event of an audit.

If the pathology report on the removed healthy breast returns with a positive result, make sure 174.x becomes the primary diagnosis.

Note: Whereas the removal of the breast with the neoplasm was a modified radical mastectomy (19240), the simple mastectomy of the healthy breast would be coded 19180 (mastectomy, simple, complete).