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Outpatient Facility Coding Alert

Reader Questions:

Rely on 19499 for Unlisted Breast Procedures

Question: A patient had a mastectomy and had to be brought back to the operating room to look for a bleed as she developed a hematoma at the surgical site. The physician explored the wound for the bleed and cauterized two different areas. What CPT(R) code would I assign for the reopening of the surgical wound with cauterization? 

Ohio Subscriber

Answer: Since there is no proper code for this particular procedure, you have to resort to unlisted code 19499 (Unlisted procedure, breast). You can use 19499 for any breast procedure that cannot be reported using any of the available codes. It is better to consult the physician to ensure that proper documentation has been done before billing for an unlisted procedure.

You’ll need to add modifier 78 (Unplanned return to the operating/ procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period), as it is an unplanned return to the operating room during the postoperative period.