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Breast Reconstruction and Modifier 59

  1. #1
    Location
    Adirondack Chapter of Professional Coders, Glens Falls, NY
    Posts
    26
    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.
    WSRCPC

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