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partical mastectomy and adjacent tissue-transfer

Rebecca Posted Tue 10th of September, 2019 12:06:28 PM
partial mastectomy -Right Breast 19301-RT adjacent tissue-transfer 84 sq cm 14301-51,RT, 14302 -RT, deep right sentinel lymph node biopsy 38525-RT, Mapping 38900-RT. Insurance is stating that its not appropriate to report adjacent tissue transfer to CPT 19301, because closure is included in the work represented by code 19301. Cpt code 14302 denied add on code to 14301. How can this be ??? No NCCI edits come up when I enter these codes in the super coder edit checker. I ran a similar case by "ask an Expert" and I was told I had coded it correctly. Please help
SuperCoder Answered Wed 11th of September, 2019 10:13:33 AM

Hi,

Thanks for your question.

Code 19301 suggest that the partial mastectomy is performed to eradicate cancerous (or suspected to be cancerous) lesions or a lump in the breast through an open and incisional process. A physician makes an incision with a scalpel over the lump and the suspected lump is excised along the margin. Any additional lesions in the area are checked and also removed. When all cancerous or suspicious tissues are eradicated, a drain is placed, the surgical wound is closed, and dressing is applied.

As per this code description the closure of surgical wound is also included.

To code for ATT (14301-14302) there should be strong medical necessity be established to code these codes for closure of the partial mastectomy.

Please feel free to ask, if you have further questions.

Thanks.

Rebecca Posted Tue 24th of September, 2019 12:09:57 PM
I reviewed this the CPT assistant . So If it took the doctor several hours because of the ATT I suppose modifier 22 could be added to CPT code 19301.(however ATT/R is not a simple, intermediate, or a complex layered closure-its a rotation flap, Z-plasty, W-plasty , V-Y plasty)- (ugh) I was thinking maybe coding the ATT (cpt code 14301-14302) instead of 19301 (14301-14302 has higher rvu then 19301) maybe ok but then the 38525 and 38900 would not get paid because of the parent code not being billed with it (cpt 19301). So.....seems that 19301-22 is the correct way to code. Please let me know you there are any other options. My doctor spent 5 1/2 hours in surgery. TY CPT® Assistant. October 2017; Volume 27: Issue 10 Surgery: Integumentary System Question: Is it appropriate to report Current Procedural Terminology (CPT®) code 14000 or 14001 for a subcutaneous advancement flap for closure after a lumpectomy (or partial mastectomy)? Answer: No, it is not appropriate to report either code 14000, Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less, or 14001, Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm, in addition to code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy), because simple, intermediate, and complex layered closure is included in the work represented by code 19301.
SuperCoder Answered Wed 25th of September, 2019 08:58:10 AM

Hi,

As per the documentationand CPT assistant article, it suggests modifier 22 should be appended with 19301. 

Also, in order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:

–Increased intensity

–Additional time

–Technical difficulty

–Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician.

An unusual procedure is not when the physician took only a few extra minutes on the patient’s case or when the physician documents that the procedure was only slightly more difficult. There is an average range of difficulty for every procedure. A procedure could be slightly more difficult and still meet the definition of the procedure and not warrant appending modifier 22.

Hope this helps.

Thanks.

Rebecca Posted Wed 25th of September, 2019 11:48:30 AM
I get it. am up on modifier 22. This have nothing to do with super coder. I just cant be that they don't allow for ATT/R. There are differents between simple ,intermate and complex closures I just feel that the physician should get more reimbursement if something that required a more complex closure, that required additional time. Ill review this info with my physician and the requirements for modifier 22. TY so much for your help.
SuperCoder Answered Thu 26th of September, 2019 05:47:45 AM

Thanks. You're correct that the physician should get more reimumbersement for additional time he spent.

Happy to help.

Thanks. 

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