AAPC - Back to school
Results 1 to 4 of 4

Thread: Excision of breast scars/tissue

  1. #1
    Join Date
    Apr 2007

    Default Excision of breast scars/tissue

    AAPC: Back to School
    Anyone have any ideas what CPT code I should use?? Little confused on this particular case... Thanks

    PREOPERATIVE DIAGNOSIS: Bilateral breast scars status post breast

    POSTOPERATIVE DIAGNOSIS: Bilateral breast scars status post breast

    1. Excision of scar tissue around the left nipple-areolar complex.
    2. Reconstruction of nipple-areolar complex.
    3. Reconstruction of bilateral lower breasts after excision of scar
    and abnormal breast tissue.

    DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient was
    prepped and draped in a sterile fashion. The patient had abnormal
    breast tissue extending below the mastopexy reduction and bilateral
    inframammary folds. Abnormal tissue was identified and marked. It
    was excised with a 15-blade scalpel as well as Bovie cauterization.
    All abnormal tissue was removed. The lower pole of the breast as
    well as the inframammary fold were reconstructed by tacking the
    inframammary fold and sewing the overlying tissue, all with
    resorbable sutures.

    The left nipple-areolar complex was identified. A cookie cutter was
    used to mark these and match the size from the right side to the left
    side. Excess scar tissue around the superior, medial and lateral
    two-thirds was completely excised to normalize the nipple-areolar
    complex. The nipple-areolar complex was closed in a Benelli type
    pattern, reconstructing with resorbable sutures.

    The patient tolerated the procedure well with no complications. The
    patient was sent to recovery in good condition.

    SPECIMENS: Included bilateral breast tissue.

  2. #2
    Join Date
    Apr 2007


    Sounds like a mastopexy 19316 to me and on the contralateral side seems to be a scar revision reporting complex closure for total defect modifier w/59. Try to find out how much breast tissue was taken, may shine another light on things( mini reduction?)

    or it can be

    13102 times X

    Thats plastic surgery for ya, confusing, oh and the op note is really vague.


  3. #3
    Join Date
    Apr 2007

    Default excision breast scars/tissue

    also look at 19380. It may take care of your surgery as well.

  4. #4
    Join Date
    Apr 2007
    New Port Richey & Gulf to Bay

    Question What About This One?!

    Hello Everyone,

    Funny thing is I have a similar question. I also posted this in AHIMA's COP. See Blow:

    I work for the ASC setting. I was wondering if someone could direct me to the correct CPT for this case.

    The provider admitted a patient for revision of bilateral breast reconstruction for a patient that developed bilateral breast wounds, status post history of breast cancer. However, when reading the operative report, it seems for one breast, he is not performing a true breast reconstruction.

    "At this time, attention was directed to the right breast. The eschar which had been seperated was dissected free from its base and removed in toto and was sent for permanent pathology. At this time, there was noted to be good granulation tissue at the base. There was no wound opening with no exposed implant. The area was widely irrigated with bacitracin irrigation. Hemostasis was assured using electrocautery. After which, attention was turned towards the left breast reconstruction."

    Do you report this with 19120 or perhaps a code from the benign skin lesions (i.e. 11400-) or would you still consider this a revision of breast reconstruction, regardless that the provider did no tissue rearrangement?

    Thank you all for your help.

Similar Threads

  1. Breast biopsy with no breast tissue
    By lindacoder in forum Diagnosis Coding
    Replies: 1
    Last Post: 07-20-2015, 11:50 AM
  2. excision breast tissue - Pt first wanted breast reconstruction
    By diann in forum Outpatient Facilities
    Replies: 3
    Last Post: 10-19-2010, 07:49 PM
  3. excision of multiple scars on the face
    By KNP40806 in forum Plastic Surgery
    Replies: 4
    Last Post: 10-20-2009, 09:17 AM
  4. Breast Tissue Expanders
    By tgutierrez in forum Outpatient Facilities
    Replies: 2
    Last Post: 06-26-2008, 10:34 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.