Wiki Help please! Need correct codes for this procedure!!

[jdibble]

Hi all! I posted this question before but did not get an answer and I really need help!!!
Can someone look at this note and give me feedback on what codes to use? I originally was going to use 19370-50, 11907-50, dx V51.0, V45.71, V10.3, but then I saw info on here that I should use 19342-50 instead. The doctor wants the first code set because the RVU's are higher with dx 174.9.

PREOPERATIVE DIAGNOSIS: Bilateral breast cancer.

POSTOPERATIVE DIAGNOSIS: Bilateral breast cancer.

PROCEDURES PERFORMED: Exchange of tissue expanders for bilateral permanent saline implants, capsulotomies bilaterally, and contouring the capsule in order to facilitate symmetry.

ANESTHESIA: General

OPERATIVE FINDINGS: The tissue expanders were intact that were removed and the replacement implants on the left side were a Natrelle saline-filled breast implant, Style 68MP. The total volume of saline was 240 cc, reference #68-210, serial #16015639. On the right side, Natrelle saline-filled breast implant, 68MP is the style number, reference #68-210, serial #15179004, 240 cc of saline total volume.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room and prepped and draped in the routine sterile fashion. A time-out was performed. The existing incisions were marked out along the breasts. On the right side, care was taken to avoid re-incising the portion of the incision that had problems with wound healing. On the left side, there were no problems with wound healing and the incision was recreated. The patient had markings done in the preoperative holding area. These were used as guides and marked with methylene blue in the operating room. The incisions were injected with local anesthetic containing epinephrine and then some of the key areas along the breast pockets were injected as well. The incisions were created sharply, full thickness, through skin into subcutaneous tissue. Immediately, the tissue around the implant was visible. Subcutaneous undermining was performed inferiorly in a stair-step manner of gaining access onto the breast implant. The capsule and AlloDerm interface was incised transversely and the expanders were immediately visible. The expanders were removed and passed off as a gross pathology specimen. The breast envelopes were carefully evaluated. The capsules appeared mature. The AlloDerm was well incorporated and there were no problems. There was existing asymmetries in the breast shape and in order to facilitate as symmetrical as possible a result, capsule scoring was performed along the base of the capsule in key areas as well as tangential scoring anteriorly along the capsule in 2 areas on the right breast and in 1 area on the left breast. There was additional contouring of the inframammary fold on the left breast in order to facilitate a smoother breast implant contour. Sizers were then brought into the field. The patient was sat up and it was determined that the final size of the breast would be approximately 240 cc of saline in the implant. The sizers were removed and then the permanent breast implants were brought up to the field. The breast envelopes were carefully irrigated with saline. Hemostasis was rechecked prior to closure and then a triple antibiotic solution was instilled into the breasts, then allowed to fit while the implants were being prepared. The implants were placed in a triple antibiotic solution using a no-touch technique and there were no complications during the closed filling system. A total of 240 cc of saline were placed into each saline breast implant. Closure was performed in layers with a deep dermal 4-0 interrupted PDS suture followed by a running subcuticular closure and Dermabond. Hemostasis was maintained during the case with the Bovie. The patient had a surgical bra placed at the end of the case. The patient had no intraoperative complications. She was awoken in the operating room without complications. She was taken to the recovery with a LMA in place on a T-piece and later that was removed without problems.

**addendum - recevied EOB from Coresource denying the 11970 as procedure was billed with another procedure that, by clinical, practice standards should not co-exist during the same session.

Please let me know which is the correct CPT and DX for this note!

Thanks,

 

[FTessaBartels]

I'm not sure

I am NOT an expert in coding breast surgeries ... but here are my thoughts

1) 19370 and 11970 do not appear to bundle when I checked through Encoder Pro

2) Documentation does not seem to match 19370 lay description: An open periprosthetic capsulotomy on the breast is done by making an incision in the skin of the breast, at the site of a mastectomy scar, in the skin fold beneath the breast, or around the nipple. The physician uses a cautery knife to cut into the area of fibrous scarring associated with a breast implant. Incisions are made into the scar (contracted capsule) to cut around its circumference and enlarge the pocket in which the prosthesis is placed. Loosening the capsule relieves pain and tightness caused by the contracture. No tissue is removed. The incision is repaired with layered closure.

3) Documentation does seem to match lay description for CPT 19342: The physician inserts a breast prosthesis after a patient has had previous breast surgery. Delayed insertion is done at a later time, usually after the wound has healed, and may be several months after the original surgery. The physician makes an incision in the fold under the breast or along a previous surgical incision and dissects the tissue and muscle layer free from the chest wall to accommodate a prosthesis positioned under the muscle. As an alternative, the prosthesis may also be positioned between the muscle and the existing breast tissue or skin. The incision is repaired with layered closure.

You cannot code based on what will give you the higer RVU. You have to code based on what the documentation supports.

Did you already appeal with operative note?

Hope this helps.

F Tessa Bartels, CPC, CEMC

 

[jdibble]

Thanks You!

Thanks Tessa - this does help me quite a bit!!

You have stated exactly what I had thought the report read. Now if only I can get the doctor to understand. She is the one who wants to choose her procedure codes based on her higher RVUs and I go round and round with her about this - I just gave up and submitted the other claim as she insisted and now it denied. The surgery I just posted is a current one and she insisted it be sent out the same way as the other one with the excuse that it had paid. We just got the EOB today showing it didn't.

We are in the process of sending the notes in for an appeal. The OP note for the denied claim even states in the body of the report that the capsule was without abnormality!! The way I read that one I see that she really only did the exchange of the tissue expander and not the capsulotomy even though insurance paid the capsulotomy. We are sending in the notes to the insurance to see if they will pay the additional code and to let them decide if they even see the capsulotomy procedure in that note. This maybe our only way to get though to this doctor.

Thank you for answering my question!