Victoria Posted Tue 29th of October, 2019 11:55:12 AM
What would be the best code for: A sterile 18-gauge needle was used to puncture the tissue expander and egress of clear saline noted. Sterile bulky absorbent dressings were applied followed by a compressive garment?
SuperCoder Answered Wed 30th of October, 2019 03:05:33 AM
Thank you for your question.
The appropriate code to use for subcutaneous injection of filling material (eg, collagen, saline) for tissue expander will be from series 11950 to 11954. Feel free to ask for any further query.
Victoria Posted Wed 30th of October, 2019 10:25:21 AM
The procedure was actually deflating tissue expanders of saline by aspirating in the office.
SuperCoder Answered Thu 31st of October, 2019 09:33:02 AM
Thank you for more clarity, in that scenario the appropriate code for deflating tissue expanders by aspirating saline in breast will be 19330 (Removal of mammary implant material). However, if it is other than breast, we will go for unlisted code.
Victoria Posted Thu 31st of October, 2019 10:01:47 AM
19330 description states the physician makes an incision. The doctor only aspirated.
SuperCoder Answered Fri 01st of November, 2019 06:01:11 AM
Since, there is no appropriate CPT® code for deflating the breast implant, it is advised to report code 19499 (Unlisted procedure, breast) for the above-mentioned scenario. Also, you should include a cover letter stating why you are using the unlisted procedure code. This separate report should explain, in simple, straightforward language, exactly what the physician did.
However, we may use 19330 (Removal of mammary implant material) as comparison code if unlisted code is not accepted by private payer. Hope it helps.