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Emily Posted Tue 16th of January, 2018 16:55:56 PM
Patient previously underwent bilateral mastectomies followed by tissue expander breast reconstruction. Subsequently she presented with positive posterior margins and since the anterior fascial sheath was already taken from the pectoralis muscle during the previous surgery, the pectoralis muscle was removed completely in the area of the new positive margins and sent to pathology. In short the tissue expander was removed and the pectoralis muscle was partially excised in the area of positive margins. The muscle specimen was 8cm in size that was removed. The tissue expander was then reinserted under the lattissmus muscle. What CPT should I use for the partial removal of the pectoralis muscle?
SuperCoder Answered Wed 17th of January, 2018 06:29:05 AM

Hi Emily,

If the surgeon returns the patient to the operating room during the global period of the initial excision, be sure to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 19303 or cpt 19120, as appropriate if performed out of global period. Please feel free to ask for any further query.

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