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19342 with 19316

  1. #1
    Question 19342 with 19316
    Medical Coding Books
    I have a surgeon who wants to bill a bilateral delayed insertion (19342-50) with a RT Mastopexy (19316-RT). According to CCI these are mutually exclusive...
    Here is the OP note in short form...

    PreOp Dx: Hx of prev partial Lt mastectomy

    1. Bilateral augmentation of the breast for symmetry purposes following partial mastectomy.
    2. Rt mastopexy for symmetry purposes following left partial mastectomy.

    Procedure in Detail:
    Pt brought to preop hold area....Left side addressed first. An inframammary fold incision was made approximately 2.5cm in length and carried through skin and subcutaneous tissue and the breast tissue to the border of the pectoralis major muscle which was released along the length of the inframammary fold approximately 1.5cm up from the fold. Contralateral procedure was done in a similar fashion... Symmetry was achieved with asymmetric volumes of the implants; however, additional contouring for shap and position of the nipple areolar complex was addressed with the mastopexy...The nipple areolar complex was elevated and "tacked" into position. The wedge component was then resected. Full-thickness wounds closed...

    Any feedback or ideas on how to code this would be greatly appreciated..
    Thanks so much!

  2. Default
    I would code this as 19340-50, 19316-RT because this is immediate insertion following mastopexy, mastectomy or in reconstruction.
    19342 is for days-months after mastopexy, mastectomy or in reconstruction.

  3. #3
    THANK YOU!!! That was exactly what I needed...the clarification on immediate vs. delayed. I really appreciate your help!

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