Results 1 to 2 of 2

Breast Reconstruction and Modifier 59

  1. #1
    Adirondack Chapter of Professional Coders, Glens Falls, NY
    Question Breast Reconstruction and Modifier 59
    Medical Coding Books
    My doctor is charging the following codes for a breast reconstruction for one of our patient:

    15734 - Muscle Myo/Fasciocutaneous flap-trunk
    19371 - capsulectomy, periprosthetic breast
    19328-59 - removal of intact mammary implant
    19357-59 - breast recon. w/tissue expander, including subsequent expansion

    The insurance company (MVP) paid for 15734 and 19371, but said that 19328 and 19357 are integral to 19371. I can understand how they could say that the removal of the implant would be considered part of the capsulectomy procedure, but I cannot find any CCI edits or any other documentation which states that 19357 is inclusive to ANY of these procedures. Am I missing something?

  2. #2
    Default Code 19328 and code 19357 are MUTUALLY EXCLUSIVE. A modifier is allowed to override t
    Code 19328 and code 19357 are MUTUALLY EXCLUSIVE. A modifier is allowed to override this relationship.

    Modifier 59 is placed on both codes? Shouldn't it only be on the column 2 code 19327-59. You are right you would need a modifier to support seperate session, seperate site, bilateral. If he is doing in the same anatomical site than they would be inclusive and only pay the 19328.

Similar Threads

  1. Breast Reconstruction - appropriate to code
    By ross9763 in forum Billing/Reimbursement
    Replies: 1
    Last Post: 12-02-2015, 08:12 PM
  2. Breast Reconstruction
    By RobinSewell in forum ICD-10
    Replies: 1
    Last Post: 11-04-2015, 12:44 PM
  3. breast reconstruction
    By nc_coder in forum Plastic Surgery
    Replies: 3
    Last Post: 12-18-2014, 12:11 PM
  4. Breast Reconstruction - necessary surgery
    By weshelman in forum Plastic Surgery
    Replies: 0
    Last Post: 07-25-2012, 07:07 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.