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Can both a Gynecomastia mastectomy and Mastopexy be billed?

  1. #1
    Daytona Beach, FL
    Exclamation Can both a Gynecomastia mastectomy and Mastopexy be billed?
    Medical Coding Books
    I'm hoping someone can help me with this. We billed out for the Gynecomastia with 19300 but now the Plastic office staff is questioning if we can also bill for a Mastopexy 19316 since it took the doctor so long to perform the surgery.

    The following is the OP note - can someone read this and tell me if they see the documentation of the Mastopexy and if it can be billed with the Mastectomy? The Plastics office is also asking if the can charge for a Mastopexy for the Reductions that they perform - 19318.

    OPERATIVE INDICATION: This is a patient who had unilateral gynecomastia with swelling and pain of the left breast who presents for a mastectomy.

    ANESTHESIA: General.

    DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room. He was given a prophylactic dose of antibiotics. The procedural care team participated in a time-out in which the patient's name, medical record number, date of birth, site and side of operation were confirmed and agreed upon by all present. The chest was prepped and draped in a routine sterile fashion. The case was begun by instilling tumescent solution into the left breast and the upper abdomen in a subcutaneous plane. Liposuction was performed using a 4 mm cannula. A scant amount of subcutaneous tissue was removed. The attention was then turned toward the nipple areolar complex. An incision was made at the junction of the nipple areolar complex to the surrounding breast skin and then an additional incision was made that was eccentric going approximately 2 cm superior to the existing areola and less than a centimeter inferiorly. The area between the 2 incisions was deepithelialized. The area between 3 o'clock and 9 o'clock was used to gain access to the breast. The area between 9 o'clock and 3 o'clock, which is the superior part of the areola, did not have any full thickness incisions. Preserving 1 cm depth of tissue under the areola, the gynecomastia tissue was separated from the nipple areolar complex and from the surrounding breast subcutaneous tissue and pectoralis muscle. There was an obvious disc of glandular tissue present immediately upon entering into the breast tissue. The breast was then evaluated and then hemostasis was maintained with the Bovie. The breast was copiously irrigated and hemostasis was rechecked and maintained with the Bovie. The total weight of the mastectomy specimen was 69 g. The incision was then closed by deep dermal interrupted suturing along the nipple areolar complex insetting it into the larger incision. Then a running subcuticular closure as well as some additional suturing with 5-0 plain was performed. A 19-French Blake drain was placed prior to closure to drain the mastectomy site. The patient had Dermabond along the incision followed by Steri-Strips, ABD, some additional gauze padding around the drain and then Ace wraps. The patient was taken to the recovery room in stable condition where he subsequently had his LMA removed. The patient was in stable condition. The total weight of the removed breast tissue was 69 g and that was sent to pathology. There were no complications. EBL was less than 50ml.

    Thank you for all the help I can get!!!
    Jodi Dibble, CPC

  2. #2
    Milwaukee WI
    Default 19300
    I don't see any specific reference in this documentation to extraordinary time or effort required.

    19300 frequently involves removing/repositioning of the areola.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Daytona Beach, FL
    Yes Tessa - that does help. I was trying to figure out where in the note the doctor had documented that she did a Mastopexy separate from the Mastectomy - but I am not familiar with both procedures and how they are done so I was not sure what I was looking at.

    Thanks for your help!
    Jodi Dibble, CPC

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