Question Coding chest wall excision in mastectomy flap for breast cancer recurrence

kathleeng

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I'm going back and forth between different codes; mainly 21601 and 19120. I'm going to summarize the OP report: "Recurrence in chest wall after undergoing mastectomies for breast cancer. Mass palpated in upper outer quadrant of right mastectomy flap. Incision full-thickness down to muscle and capsule was undertaken. Mass resected and had not penetrated through the capsule margin........ Turned over for plastics closure and implant exchange." Does anyone have any experience of this field of coding? It's still fairly new to me so I am still learning. This was performed by a breast surgeon. Any feedback would be greatly appreciated.
 

mk2001

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I'm going back and forth between different codes; mainly 21601 and 19120. I'm going to summarize the OP report: "Recurrence in chest wall after undergoing mastectomies for breast cancer. Mass palpated in upper outer quadrant of right mastectomy flap. Incision full-thickness down to muscle and capsule was undertaken. Mass resected and had not penetrated through the capsule margin........ Turned over for plastics closure and implant exchange." Does anyone have any experience of this field of coding? It's still fairly new to me so I am still learning. This was performed by a breast surgeon. Any feedback would be greatly appreciated.
21601 has coding tip "For a tumor of the neck or thorax not involving the ribs, see 21555-21557. I know you summarized the report so I wasn't sure if part of a rib was removed or not.
Hope this helps!
 

kathleeng

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21601 has coding tip "For a tumor of the neck or thorax not involving the ribs, see 21555-21557. I know you summarized the report so I wasn't sure if part of a rib was removed or not.
Hope this helps!
Good catch! No, they did not remove the rib. A couple surgery blogs said to refer to 51555 series, but I was just fixed on the "chest wall" area. So I can definitely cross 21601 off my list for this case. Do you have any other recommendations on what code this can possibly be?
 

such78

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Good catch! No, they did not remove the rib. A couple surgery blogs said to refer to 51555 series, but I was just fixed on the "chest wall" area. So I can definitely cross 21601 off my list for this case. Do you have any other recommendations on what code this can possibly be?
Is it still in global period and what is the pathology report indicated?
 
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