Breast help please

MEZIESKY

Networker
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Safety Harbor, FL
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Ok, this is a new one to me. This pt had left breast cancer 20 years ago. Had a mastectomy with reconstruction and implant on the left. Now with a bx showed left chest wall invasive ductal carcinoma and positive on the rt. for lobular carcinoma. The Dr did a Right mastectomy, but here's the tricky part. Left mastectomy , implant removal, removal of pectoralis major and minor muscles and nodes. Do I use the 19307 radical mastectomy or the 19328 removal of the inplantfor the left side ??

Thank you for any help
Marie
 

tincyr

Contributor
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You would indeed code the 19328 for the removal of the intact implant. That is totally separate from the additional mastectomy procedure performed on the left breast. However if both the pectoralis major and minor were removed, you can't use 19307 as this excludes the pectoralis major muscle. If both the axillary and internal mammary lymph nodes were removed, then I would code 19306 with a 52 modifier as the breast tissue portion has already been done. If only the axillary nodes were taken, then I would do 19305 reduced with the 52.
 
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