Wiki Ambulatory surgery center- breast surgery coding help!

[adw10]

I am not specialized in ambulatory surgery and need some assistance with CPT for the ambulatory surgery center side. Please see example below....what CPT's would you use?

This is what was provided from another biller. I just want to ensure they are coding this correctly.
15002 - LT
15002 - RT
19316 - LT
19380 - LT
19380 - RT
19120 - RT
13101

Preoperative Diagnosis:

1. Breast cancer.

2. Breast asymmetry.

3. Left breast ptosis.

4. Right breast nipple inversion.

5. Asymmetry of the right breast relative to the left.

Postoperative Diagnosis:

1. Breast cancer.

2. Breast asymmetry.

3. Left breast ptosis.

4. Right breast nipple inversion.

5. Asymmetry of the right breast relative to the left.

Procedure Performed:

1. Left mastopexy.

2. Revision of right nipple-areolar complex.

3. Wedge excision of the right lateral breast.

4. Fat grafting of bilateral breasts with donor site at the abdomen.




There is no documentation about length of closures.

 

[OpenClaims]

Hello,

This would be a case that the description of the procedure would have to present. As a coder i do not code from the "Procedures performed" area. It is the description of the procedure area where you will find all of your relevant information. So my first thought is for the Wedge excision. Did the physician pay attention to the margins, because this will completely change your coding? The 15002 is for the preparation, but there is not the actual "grafting" procedure code used in your example above. Does the description of the procedure also state the amount of time spent of the preparation of the grafting, along with the grafting? Also for the closure, if its not documented it wasn't done.

I am sorry I could not be of more help with this scenario, but I can take a look at the full op note if you would like to get a better understanding of the correct coding for this instance.
Thanks
Misty

 

[adw10]

I agree! I have also told the practice that we need time, closure (size), ect. So, another question, do you code for an ambulatory facility as well? How would you code the facility charges?

 

[OpenClaims]

I agree! I have also told the practice that we need time, closure (size), ect. So, another question, do you code for an ambulatory facility as well? How would you code the facility charges?

I am sorry i do not code for a facility (ASC)