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re-vesion of a simple mastectomy

Rebecca Posted Mon 25th of March, 2019 17:37:24 PM
PT HAD SURGERY ON 2/15/19 19303-50(in a modification of simple mastectomy, skin and nipple maybe spared but all subcutaneous tissue is removed), 38525-LT, 38900-LT DX D05.12 X40.01 PT RETURNS TO THE OFFICE 2/27/19 WITH POST-OPERATIVE NECROSIS/INFECTION (L76.82)–PT IS COUNSELED FOR A LONG TIME SHE THEN RETURNS ON 3/6/19 HER SKIN IS STARING TO PEEL AROUND THE INCISION AND 60CC OF FLUID IS REMOVED FROM THE INFECTED AREA–SHE IS DIABETIC-A DECISION FOR SURGERY IS MADE. 3/7/19 THE PT RETURNS TO THE HOSPITAL FOR SURGERY A BILATERAL REVISION MASTECTOMY THE INSURANCE IS MEDICARE-I BELIEVE THAT WE CANT BILL ANYTHING FOR DOS 2/27 AND 3/6 BECAUSE THE VISITS ARE A RESULT OF A SURGICAL INFECTION/COMPLICATION FOR 3/7/19 SURGERY HOW IS THIS CODED ? I HAVE REVIEWED SEVERAL CASE SCENARIOS THROUGH ASK AN EXPERT AND AM STILL NOT REALLY SURE IN HOW TO CODE THIS ….19304-58-50???? . REVIEWED THE ATT/R AND 13000 CODES AND I DON’T FEEL THE SURGERY WOULD FALL UNDER THOSE EITHER….19303-52???? I have another claim where the insurance denied 19303 they would only pay for once IN A LIFETIME. Pre-Op Diagnosis Epidermolysis and necrosis of mastectomy flaps, bilateral following bilateral skin sparing, nipple preserving mastectomy Postoperative wound infection, superficial and deep, present at time of surgery The patient is afebrile, there is no evidence of sepsis, there is a leukocytosis, mastectomy flap necrosis, inflammation, epidermal lysis, and pus draining from the wound. Ductal carcinoma in situ, left breast Post-Op Diagnosis: (1) Acquired epidermolysis bullosa Procedure Performed: Mastectomy, revision, bilateral, with resection of skin flaps and nipple areolar complexes which had been preserved at her original skin sparing and nipple preserving mastectomy Specimen Removed: Right superior flap and nipple areolar complex Left superior flap and nipple areolar complex New margin, left inferior flap New margin, left superior flap, medial Gram stain culture and sensitivity right Gram stain culture and sensitivity left Complications: None Drain: JP, HemoVac... - medium Sponge/Needle Count: Correct Procedure Description This is a very pleasant 59-year-old lady who on February 15, underwent a bilateral skin and nipple preserving mastectomy with a left axillary sentinel lymph node biopsy. She has been doing well postoperatively, at home, although developed epidermolysis of patches of skin of the superior flap of both breasts, patches of tissue necrosis, and compromise viability at the nipple areolar complexes. She presents to the operating room today for revision mastectomy. The plan is to remove the preserved skin and nipple areolar complex of the superior flap of each breast and convert her skin and nipple preserving mastectomy to a traditional simple mastectomy. In so doing, the epidermal lysis and necrotic tissue would be resected. Indications risks and benefits of surgery were reviewed, questions answered, she presented today ready to proceed. There is infection present at time of surgery. There is no fever, although there is an elevated white blood cell count, tissue epidermal lysis, erythema, necrosis, and pus draining from the wound. A decision for surgery was made Additional operating time was needed with this case in particular to allow for hand sewn, interrupted nylon closure of the mastectomy wounds in this morbidly obese lady with diabetes, and a BMI greater than 43. So modifier 22 After obtaining informed consent which includes pain, bleeding, infection, other undesired and unintended events the patient is brought to the operating room placed in a supine position prophylactic IV antibiotics delivered pneumatic compression stockings fitted general endotracheal anesthesia induced. Both breasts, and anterior chest wall were prepped and draped using a wet prep. A timeout was performed and confirmed. Skin clips were removed wounds were open specimens were collected for Gram stain culture and sensitivity. On the right, the superior flap was mobilized, and a point of transection was identified sharply incised and then the skin and nipple areolar complex were resected with electrocautery. Specimen was placed off the field with a suture placed laterally. The wound was copiously irrigated, debrided with a gauze, a 19 French round Blake drain was brought into position under the superior flap. The skin was closed with interrupted horizontal mattress sutures. This did require additional operating time, and was performed due to her diabetes, loss of tissue viability, risk of infection, and the long-term security of having nylon sutures in place until the wound is completely healed. Attention was turned to the left breast. Sutures were removed, specimen was collected for Gram stain culture and sensitivity, skin markings made to transition from skin sparing and nipple preserving mastectomy to a traditional mastectomy skin incised subcutaneous tissues divided with cautery. Specimen was passed off the field with a suture placed laterally. A decision was made to resect residual subcutaneous tissue of the inferior flap. It was resected, and oriented with a long blue suture lateral short blue medial and white suture inferior. Likewise, an additional segment of subcutaneous tissue was resected from the medial aspect of the superior flap, with a long blue suture lateral short blue medial and a white suture superior. I did hand carry the specimens to pathology and reviewed them with the pathologist for proper orientation. The wound was copiously irrigated, debrided with a gauze, 19 French round Blake drain brought into position out through separate stab incision sutured to the skin with a 2-0 nylon and then once again the wound was closed systematically with interrupted horizontal mattress nylon sutures, this did require additional operating time
SuperCoder Answered Tue 26th of March, 2019 09:12:35 AM

Hi Rebecca,


Thanks for your question.


As per the documentation, it is clear that earlier mastectomy was performed sparing the skin and nipple. In such case, you should have billed CPT code 19304, which is a kind of skin–sparing subcutaneous mastectomy.


Now at this time, the patient is in because of the infection and the physician has performed the complete mastectomy including skin and nipple. So, in this case you should now report CPT code 19303 with modifiers 58 and 50 since physician is removing skin and nipple.


Please feel free to write if you have any question.



Rebecca Posted Tue 26th of March, 2019 10:59:38 AM
I had a feeling that was how this was going to come back/ The mastectomy that the doctor did the first time was not a subcutaneous mastectomy (19304). CPT code 19303 -The breast tissue is removed, along with a portion of skin, including the nipple. In a modification of the simple mastectomy, skin and nipple may be spared... which in this pts case it was. As per the doctor you cant remove "all" the subcutaneous tissue otherwise the remaining tissue would die. Records for this procedure were submitted to the insurance because the procedure took longer then usual because of the pts breast size and obesity. Maybe on the first claim we should have billed 19303-50-52-22 OMG would at even make since to the insurance :)
SuperCoder Answered Wed 27th of March, 2019 08:28:01 AM

The medical record documentation provided by you clearly shows that the initial surgery was skin–sparing subcutaneous mastectomy and now the physician is removing skin and nipple. So according to that we suggested you the correct codes. Please confirm with the medical record carefully and let us know in case you need any further help.



Rebecca Posted Wed 27th of March, 2019 17:52:04 PM
TY - ill review op report/procedures with the doctor / what about the f/u visit after the first surgery -drained fluid from the surgery site....thats part of the global surgical package..... a decision was made to take the pt back to the OR the next day. TY
SuperCoder Answered Thu 28th of March, 2019 04:24:56 AM

Hi Rebecca,


As per CMS, follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery are included in the global period and should not be reported separately.



Rebecca Posted Mon 01st of April, 2019 10:02:12 AM
That's whats I figured. TY …………could I please get your feed back regarding this information. Coding for nipple-sparing and skin-sparing mastectomies by ERIC WHITACRE, MD, FACS, MEGAN MCNALLY, MD, FACS AND JAN NAGLE, MS, RPH PUBLISHED MARCH 1, 2017 • PRINT-FRIENDLY In December 2007, an American Medical Association (AMA) CPT [Current Procedure Terminology] Assistant Newsletter article was published indicating that a skin-sparing mastectomy should be reported with CPT* code 19304, Mastectomy, subcutaneous.1 The CPT article incorrectly indicated that nipple-sparing does not change the subcutaneous dissection performed. The correct code to report skin-sparing mastectomy is 19303, Mastectomy, simple, complete (total mastectomy). It is worth noting that the American College of Surgeons (ACS) did not provide the coding interpretation published in this 2007 CPT Assistant Newsletter article regarding the code to report for skin-sparing mastectomy. Moreover, the American Society of Breast Surgeons (ASBrS) was not a member of the AMA CPT Advisory Committee in 2007 and, therefore, could not contribute to CPT Assistant Newsletter articles. In 2015 the ACS submitted a clarification to the 2007 CPT Assistant Newsletter article, which was published in the March 2015 issue.2 However, the earlier 2007 article was not deleted, retracted, or marked in any way to indicate that the information featured in the article was incorrect. Because the 2007 and 2015 articles are both maintained in the CPT Assistant Newsletter archives, confusion persists regarding correct coding for skin-sparing and nipple-sparing mastectomies. Some coding consultants continue to direct surgeons and coders to incorrectly report 19304 for procedures that should be reported with 19303. Distinctions between complete mastectomy and subcutaneous mastectomy A skin-sparing or nipple-sparing mastectomy for diagnosed carcinoma, or for patients who are at high risk for carcinoma, is reported with code 19303 regardless of the amount of skin removed or whether the nipple is preserved. These oncologic procedures require removal of the entire breast tissue in one or both breasts plus additional surgical work, such as attention to surgical margins, specimen orientation, and cold ischemic time. In contrast, subcutaneous mastectomy is typically used to treat patients with severe symptomatic fibrocystic change or patients who are undergoing breast cosmetic procedures in which significant tissue removal is necessary to achieve symmetry. The incision is generally conservative and cosmetic, and some breast tissue is left behind. Thus, it is not a “complete” mastectomy. What to include in the operative report To clarify reporting, the operative report should include the wording “nipple-sparing complete mastectomy” or “skin-sparing complete mastectomy,” as well as the appropriate International Classification of Disease, 10th Revision, Clinical Modification code for diagnosed malignancy (such as C50.XXX or D05.XX) or for increased future breast cancer risk (such as Z15.01). Use of the specific term “complete mastectomy” will help direct the coders to correctly report 19303, Mastectomy, simple, complete. This change is consistent with Version 1.2017 of the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Breast Cancer Risk Reduction: “Nipple-sparing mastectomy is a total mastectomy with preservation of the nipple/areola and breast skin. Efforts should be made to minimize the amount of residual breast tissue.”3 The distinction between a simple, complete mastectomy and subcutaneous mastectomy is similar to the biopsy/lumpectomy distinction, which also led to coding confusion a decade ago due to incorrect coding advice. Today, it is well understood that these procedures are not reported based on the volume of tissue removed, but rather on the intent to achieve negative margins. For example, excision of a 4 cm fibroadenoma in a 19-year-old patient is reported with code 19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions (breast biopsy). In contrast, excision of an 8 mm carcinoma via a 2.5 cm surgical specimen is reported with code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy). To summarize, report code 19303 for a skin-sparing or nipple-sparing mastectomy for diagnosed carcinoma or for patients who are at high risk for carcinoma, regardless of the amount of skin removed or whether the nipple is preserved. The “Coding and practice management corner” column in the September 2014 Bulletin provides additional guidance on breast surgery coding.4
SuperCoder Answered Tue 02nd of April, 2019 09:05:48 AM
Rebecca Posted Wed 03rd of April, 2019 12:16:48 PM
NP TY --- I can't access the second article 152291 could you please provide me that article TY
SuperCoder Answered Thu 04th of April, 2019 02:46:11 AM
Please find below the contents of the required article.
"Question: The provider performs subcutaneous mastectomy of the right breast, and inserts an implant as well. How do we code for this scenario
Answer: Subcutaneous mastectomy is a lesser known term as compared to partial or radical mastectomy. This is a skin sparing removal of the entire breast tissue, through an incision under the breast, sparing the breast skin, nipple and areola, in case these structures are not affected by the cancer spread. The right code for this would be 19304 (Mastectomy, subcutaneous). In this case, the provider does not remove the pectoralis major, pectoralis minor as well as the adjoining lymph nodes. The provider may insert a drainage tube.
If the provider goes for an immediate implant of breast prosthesis following this, you may report 19340 (Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction).
However, in case the provider had decided to insert the breast implant after some period of time, you would report 19342 (Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction). In the facility setting, also report C1789 (Prosthesis, breast (implantable)) or L8600 (Implantable breast prosthesis, silicone or equal) for the implant itself, as per payer requirements.
Furthermore, check if the implant was custom made by the provider. In which case, you may want to report 19396 (Preparation of moulage for custom breast implant).
For biologic implant for soft tissue reinforcement, you may opt to use the add-on code +15777 (Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure) in conjunction with 19304, the primary procedure).
Lastly, to report a bilateral procedure, you may report modifier 50 (Bilateral procedure)."
Hope it helps.
Rebecca Posted Mon 08th of April, 2019 12:35:54 PM
Thank You so much
SuperCoder Answered Tue 09th of April, 2019 01:00:12 AM

Thank you, happy to help.

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