Wiki Breast surgery question

[Coastal Coder]

Good Afternoon,

I have come across something I have never seen before.

My Surgeon did a Right Simple Mastectomy w/ Sentinel node biopsy, 19303, 38525, 38900. She also did a takedown of a DIEP flap on the left side for symmetry purposes, patient does not want any reconstruction done.

Can we bill for the DIEP flap? if so what code would I use. Never seen this before.

I have attached the op note.

Thanks so much for any help.

MichelleView attachment DIEP FLAP.pdf

 

[Ritika]

Hi,

I think u should code it as 19301 as only partial breast that is lumpectomy is done only on right side and for take down of DIEP flap you should code it as s2068 which is Breast reconstruction with deep inferior epigastric perforator (diep) flap or superficial inferior epigastric artery (siea) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral. hope this helps..