Breast Recon, revision w/ Tissue expander help, two recon codes?


Flint, MI
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I'm newer to plastic surgery billing and one of the Drs. insists he can bill 19357 with other reconstruction codes because he wants to get paid for subsequent tissue expansions. For this particular procedure, he is billing a revision, 19380 and a capsulectomy, 19371. Patient had a Becker placed over 25 years ago and the saline portion leaked maybe 5 years ago and there has been significant volume loss. Since the leakage has been going on for some time, the patient needs to have the tissue expander in place.

Is the Dr right in billing these codes together given the following procedure note? Or are there better suited codes, and if so, what and where can I find the rationale to bring back to him? Thank you for your help.

...She had a previous transverse mastectomy scar. The lateral aspect of her mastectomy incision was excised, subcutaneous tissues were dissected. It seems that her implant was in the sub pectoral and subserratus location. The muscle was therefore divided and the capsule of the implant was identified. Dissection then proceeded around the implant and capsule, which were dissected together to avoid any leakage of the silicone. The entire implant was dissected in this manner. When we were at the lateral portion of the implant, there was noted to be a tubular structure that extended out laterally into the out lateral chest. It seemed to be the capsule surrounding extravasated silicone. Given the appearance it seemed that the extravasated silicone extended laterally along the implant port site. Dissection then proceeded laterally and the extravasated silicone was incised with its surrounding capsule. This extended for about 10 cm laterally. The ruptured implant and capsule were excised together. The entire capsule was excised intact. The specimen was brought to the back table and a capsulotomy was performed to evaluate the implant and the patient did have a ruptured what looked like a Becker, part silicone and part saline, implant. Attention then turned laterally and I could feel a firm nodule and this was excised separately, which seemed to be a small area of extravasated silicone. It was felt that the entire capsule and extravasated silicone were excised... Next, the implant pocket was revised. The previous implant was seemed to be in the subpectoral and subserratus location. It was laterally displaced. A lighted retractor was then used and the implant pocket was revised to shift the implant more medially and inferiorly to better match the opposite side. After an adequate subpectoral and subserratus implant pocket was created, triple antibiotic irrication was used to thoroughly irrigate the implat pocket as well as subcutaneous tissues laterally....Tissue expander was chosen... air removed... implant was then placed into the subpectoral and subserratus implant pocket... sutures were used to reture the muscle giving complete muscle coverage of the implant. Given that there was an extensive amount of extravasated silicone that was excised laterally, there was a fairly large empty space in the lateral chest... placed the expander via an aseptic transfer system.


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Breast Recon

I too have just started coding plastic surgery but this is how I code this surgery......19357,19371 and 11971....does this help?