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Surgery on Contralateral breast

  1. #1
    Wink Surgery on Contralateral breast
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    We have a patient that we did a remove tissue expander with placement of breast implant CPT 11970. This is the breast cancer site.

    On the opposite breast the patient had a huge deformity secondary to a biopsy that came back benign. The doctor did a right breast implant reconstruction for correction of biopsy defect and symmetry with a breast implant placement.

    I am debating using 19325 Mammaplasty augmentation with prosthetic implant or 19342 delayed insertion of breast prosthesis following mastopexy, mastecotmy, or in reconstruction.

    My doc thinks that since there was a biopsy taken checking for cancer and it resulted in the defect that it falls in the reconstruction category. Me on the other hand am a little squirrly because there is no cancer dx on this side?

    Any input would be helpful. The insurance is medicare.....

  2. #2
    Medicare Part B Policy WPS Medicare Effective Date 04/01/1996 Revision Date 09/16/2004 Publish Date March 1996 States Affected IL MI WI MN Policy Number GSURG-032 "Indications for specific surgical procedures: BREAST reconstruction of the affected and the contralateral unaffected BREAST following a medically necessary mastectomy is covered (19316, 19318, 19324, 19325, 19340, 19342, 19350,19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396) The applicable ICD-9 codes include: V10.3, 173.5, 174.0-174.9, 175.0-175.9, 198.2, 198.81, 217, 232.5, 233.0, 610.0-610.9 "

  3. #3
    Thank you for your input. Upon further review I found where it is considered reconstruction if surgery is performed to repair a defect caused by tumor removal!!!!

    I guess my doctor does know what he is talking about!!

  4. #4
    The Womens Health and Cancer Rights Act of 1998 - states plans offering coverage for mastectomy must also cover reconstruction. This also includes surgery or reconstruction of other breast to produce symmetrial appearance.


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