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revision of a mastectomy scar

Rebecca Posted Thu 01st of August, 2019 14:22:17 PM
Revision mastectomy Pre-Op Diagnosis Breast cancer, bilateral metachronous tumors Status post bilateral mastectomy with bilateral sentinel lymph node biopsy, on the left in 2016, on the right and 2019 Redundant skin and subcutaneous tissue of the trunk, bilateral Desired mastectomy revision, bilateral Post-Op Diagnosis: (1) redundant skin and subcutaneous tissue of the torso (2) breast cancer metachronous PROCEDURE : Mastectomy revision with resection of redundant skin and subcutaneous tissue of the torso with adjacent tissue transfer: on the left dimensions being approximately 5 x 5 cm superiorly and inferiorly, total of 50 cm² on the left, on the right 5 x 5 cm for a total of 25cm² summation total of 75 cm². SPECIMEN REMOVED: Left mastectomy revision with a suture in the supero-lateral lateral position, dogear left superior, dog ear left inferior Right mastectomy revision with a suture in thesupero-lateral position, dogear right. Surgery commenced on the LEFT. An elliptical incision was created to excise her previous mastectomy scar and surrounding skin and subcutaneous tissues. Skin and subcutaneous tissues were dissected all the way through to the chest wall where a chronic seroma was identified, and drained. The specimen was removed, suture placed superiorly and laterally, out of body time noted, and forwarded to pathology. The seroma pseudo-sac was obliterated with both gauze abrasion as well as cautery obliteration. A 19 French round Blake drain was brought into position out through separate stab incision sutured to the skin with a 2-0 nylon. Redundant tissue at the lateral aspect of the wound was identified, and resected using a VY advancement flap creating superior and inferior dogears on the left with dimensions of 5 x 5 cm each. Wound was checked for hemostasis, irrigated and aspirated and skin closed with skin clips subcutaneous tissues were re-approximated with a 3-0 Vicryl, skin closed with skin clips. Surgical site was covered with a sterile towel and attention was turned to the right. Once again an elliptical incision was created to excise her previous mastectomy scar and surrounding redundant skin and subcutaneous tissues. Dissection was carried all the way through to the chest wall where only laterally on the RIGHT was a chronic seroma identified, it was smaller than that on the left. The specimen was resected, and out of body time noted, suture placed in a superior and lateral position, forwarded to pathology for permanent histologic diagnosis. The seroma pseudo-sac once again was obliterated with gauze debridement as well as cautery obliteration a 19 French round Blake drain was brought into position out through separate stab incision sutured to the skin with a 2-0 nylon and once again a YV advancement flap on the right was created although in this case there was only a superior dog ear, and it was forwarded to pathology. Wounds were checked for hemostasis, irrigated and aspirated, subcutaneous tissues re-approximated with a 3-0 Vicryl skin closed with skin clips sterile dressing applied. Patient tolerated the procedure without difficulty and transferred to the recovery room in stable condition Dx. C50.211- Malignant neoplasm of upper-inner quadrant of right female breast L98.7- Excessive and redundant skin and subcutaneous tissue L76.34-Postprocedural seroma of skin and subcutaneous tissue following other procedure Z17.0 - Estrogen receptor positive status 14301-LT (50 sq cm) 14001- RT (25 sq cm) What about the removal of the redundant skin and subcutaneous tissue??? –would I look to CPT codes 13101-13102 or 12001-12007 or 12031-12037…. or 19301 possibly? The insurance is Medicare-the path report is still pending TY
SuperCoder Answered Fri 02nd of August, 2019 05:37:39 AM

 

AAE does not provide coding/reviewing for operative reports and chart notes. SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail customerservice@supercoder.com for more information.

 

In addition to it, on the basis of review of provided codes, here are the suggestions:

ICD-10 codes are correctly used for the provided descriptors.

CPT 14301 is correct for Adjacent Tissue Transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm and CPT 14001 is correct for Adjacent Tissue Transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm.

On the other hand, CPT code ranges 12001-12007, 12031-12037 and 13101-13102 are for simple, intermediate and complex wound repair, respectively. Since, you performed excision of her previous mastectomy scar and surrounding redundant skin and subcutaneous tissues, then these series codes would not be appropriate to bill.

However, CPT code 19301 is for partial mastectomy. But, when you are performing excision of redundant skin and subcutaneous tissue along with mastectomy with the same site and same incision, then it is not appropriate to bill for the skin excision separately. In this scenario, you can append modifier 22 (Increase Procedural Services) with the mastectomy procedure.

Append modifier 22 to a surgical procedure when the physician’s work required to perform the procedure is more than is typically needed.

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.

Although, if the excision of skin and subcutaneous tissue is performed separately, then code series 15830-15839 is applicable for the excision of excessive skin and subcutaneous tissue. Out of which, CPT 15839 is the code for trunk/torso site.

 

Hope this helps!

Rebecca Posted Mon 12th of August, 2019 10:55:39 AM
I wasn't asking you to code the Op Report. I was just providing all the information to you. I have gotten controversial coding info when it comes to coding for scar revisions on previous mastectomies. I was hoping for some clarity on this matter. Am going to code this as 14301-LT and 14001-RT dx C50.11,L98.7 -I had reviewed a previous question from Feb 16th 2014 and supercoder stated that the best option for a revision mastectomy would be 13100-13102 however that OP Report did not state that the physician did adjacent tissue transfer. Am just trying to get this right :) TY
SuperCoder Answered Wed 14th of August, 2019 07:44:45 AM

Hi Rebecca,

Hope you are keeping well.

You are right, when only scar revision is performed then it is suggested to use a complex repair code out of 13100-13102. Also, as you described that it is mentioned about the adjacent tissue transfer, then do not bill CPT codes 14301 and 14001, because these are purely Adjacent Tissue Transfer or Rearrangement codes, which is not performed in your case.

However, if revision of reconstructed breast is performed then CPT 19380 is most appropriate to bill. In this procedure, 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.

ICD C50.11 and L98.7 correct for "Malignant neoplasm of central portion of breast, female" and "Excessive and redundant skin and subcutaneous tissue", respectively.

Hope this helps!

Rebecca Posted Wed 14th of August, 2019 11:10:59 AM
Just want to make sure I have complete clarity on this . Regarding my physicians Op Report the correct coding would be (ATT/R Left breast 60 sq cm ) would be CPT code 14301-LT and (ATT/R Right breast 25 sq cm) would be CPT code 14001-RT and x code C50.511 and L98.7..... correct ? TY
SuperCoder Answered Fri 16th of August, 2019 05:40:07 AM

Hi Rebecca,

Hope you are keeping well.

Since, the size of ATT at the left side breast is 60 Sq CM, then CPT 14001 (ATT, trunk) can be used for first 30 Sq CM and CPT 14301 for further 30 Sq CM, appending modifier LT with both the codes.

On the other hand, for the right breast ATT defect of 25 Sq CM, CPT 14001 (ATT, trunk) can be used with modifier RT. As per guidelines, CPT 14001 cab be billed twice for same date of service.

Also, ICDs L98.7 and C50.511 are correct for "Excessive and redundant skin and subcutaneous tissue" and "Malignant neoplasm of lower-outer quadrant of right female breast", respectively.

Hope this helps!

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