Stephanie Posted Tue 25th of June, 2019 19:06:20 PM
Hello, New to coding for a plastic surgeon. one provider performed the mastectomy and our plastic surgeon perfomred an immediate bilateral breast reconstruction with stage 1 tissue expander implant placement. The codes giving for billing are 19357-50 and 19380-50. The documentation I found online stated we wouldn't bill 19380 until after the breast reconstruction is complete. However, my doctor stated a revision is required to correct contour irregularities, deformities, etc. My provider stated that due to the extensiveness of the mastectomy, the contour of the breast would be abnormally low and asymmetrical which is supported by 19380. In the same way that implantation of the acellular dermal matrix, Alloderm, justifies the usage of the code 19380, to include an internal scaffold to support the implant, the method by which I achieve this is no less important but doesn’t involve an expensive biological prosthetic.19357 bundles w/ 19380 so I'm unsure if I should bill 19357 at all. Here's info from the note: Preoperatively, the patient was placed in the
standing position and marked out, according to the midline markings
inframammary fold markings and surface markings of the pectoralis
muscle. She was taken to the operating room, general anesthesia induced
and the chest wall prepped and draped in a sterile fashion. She
underwent bilateral mastectomy, skin-sparing method. At the conclusion of the procedure, skin
flaps were viable. Copious irrigation with cefazolin-containing saline
was carried out. Beginning on the patient's right side, the
inframammary fold was reconstructed with myriad interrupted 2-0 Ethibond
sutures placed using transfixion method between the lower mastectomy
flap and the underlying chest wall fascia at the appropriate restored
location. The inferior edge of the pectoralis muscle on the right was
elevated off the chest wall and a 13 cm subpectoral pocket developed.
Into the subpectoral space, an Allergan Style 133 MV 300 mL tissue
expander was placed after being evacuated of all air, bathed in dilute
cefazolin solution, and prefilled the initial volume 120 Ml. After
placement, the inferior edge of the pectoralis was sewn to the lower
mastectomy flap with myriad 3-0 Vicryl sutures. The incision was closed
after placement of a 10 mm flat JP drain through a separate stab wound
in the upper outer quadrant. Closure was carried out with interrupted
4-0 Monocryl, interrupted 4-0 Prolene mattress suture, and running 5-0
Attention was turned to the left side where similarly the subcutaneous
mastectomy space was irrigated with a dilute cefazolin solution. The
inframammary fold was recreated with the myriad interrupted 2-0 Ethibond
placed using a transfixion method between the lower mastectomy flap and
the chest wall fascia. The inferior edge of the pectoralis muscle was
elevated off the chest wall, creating a 13 cm diameter subpectoral
pocket; 10 mm flat JP drain was placed, emerging from the upper outer
quadrant and an Allergan 133 MV 300 mL tissue expander was placed after
being evacuated of all air prefilled with initial volume of 120 mL of
saline. The implant was put into the subpectoral pocket and the
inferior edge of the pectoralis was sewn to the lower mastectomy flap
with 3-0 Vicryl. The incision was then closed with interrupted 4-0
Monocryl, 4-0 Prolene, and a running 5-0 Prolene. Additional volume was
added to both tissue expanders, bringing the final volume to 180 mL.
Your thoughts would be greatly appreciated. Thank you.
SuperCoder Answered Wed 26th of June, 2019 05:46:14 AM
Hope you are keeping well.
We want to put it in your kind notice that Ask An Expert (AAE) platform does not provide coding or reviewing of operative reports and chart notes.
SuperCoder offers SuperCoder on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding/reviewing of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.
On your question of codes 19357 and 19380 billing:
CPT 19357 is for the (Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion). The provider may perform this procedure immediately after mastectomy or later, such as three to four weeks post mastectomy. When the patient is appropriately prepped and anesthetized, the provider makes an incision over the chest wall mainly over the pectoralis major muscles creating a pocket. He then places the expander into the pocket of the muscle, injects saline, and closes the site. He may inject additional saline over a period of weeks or months to create additional tissue expansion. This code includes any subsequent expansion the provider performs during the global period.
On the other hand, CPT 19380 is for the Revision of Reconstructed Breast. After reviewing the patient's pathophysiological report, the physician removes excess amounts of tissues, skin, and fats to reshape the breast to look like the contralateral (other) breast. If necessary, a new prosthesis can also be used. Drains are then placed and the incision site is closed. This code is a revision procedure on a already reconstructed breast to correct a problem with asymmetry. Since your surgeon performing immediate reconstruction post mastectomy, then CPT 19380 would not be correct to use at this point of time. However, CPT 19357 seems appropriate to bill for immediate reconstruction. Modifier 50 is correct to use when performing the procedure on both the sides. Also, it is suggested to keep your documentation clear, which surgeon performed which part of the surgery and use appropriate modifier when there are two surgeons are involved in the same surgery session.
Hope this helps.
Stephanie Posted Wed 26th of June, 2019 11:03:10 AM
Thank you for your feedback. I will try to post my question and thoughts in a more appropriate format.
SuperCoder Answered Thu 27th of June, 2019 02:20:29 AM
Thank you, happy to help.