Outpatient Facility Coding Alert

Published on Mon Oct 17, 2016 PDF

Question: The provider performs subcutaneous mastectomy of the right breast, and inserts an implant as well. How do we code for this scenario?

Texas Subscriber

Answer: Subcutaneous mastectomy is a lesser known term as compared to partial or radical mastectomy. This is a skin sparing removal of the entire breast tissue, through an incision under the breast, sparing the breast skin, nipple and areola, in case these structures are not affected by the cancer spread. The right code for this would be 19304 (Mastectomy, subcutaneous). In this case, the provider does not remove the pectoralis major, pectoralis minor as well as the adjoining lymph nodes. The provider may insert a drainage tube.

If the provider goes for an immediate implant of breast prosthesis following this, you may report 19340 (Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction).

However, in case the provider had decided to insert the breast implant after some period of time, you would report 19342 (Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction). In the facility setting, also report C1789 (Prosthesis, breast (implantable)) or L8600 (Implantable breast prosthesis, silicone or equal) for the implant itself, as per payer requirements.

Furthermore, check if the implant was custom made by the provider. In which case, you may want to report 19396 (Preparation of moulage for custom breast implant).

For biologic implant for soft tissue reinforcement, you may opt to use the add-on code +15777 (Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure) in conjunction with 19304, the primary procedure).

Lastly, to report a bilateral procedure, you may report modifier 50 (Bilateral procedure).