Victoria Posted Thu 27th of July, 2017 10:13:39 AM
What is the best CPT code to use for the following description of the procedure?
An ovoid incision was made incorporating the edges of the open defect extending up towards the areola and inferiorly down to the mid portion of the vertical scar. This was excised with curved iris scissors and there was evidence of central full thickness defect beneath the fibrinous exudate. Underlying this was a 10 cc seroma of clear serosanguineous fluid which was suctioned out. The alloderm was not present at this area as expected. Careful inspection of the inferior portion towards the IMC showed that this was folded over on itself. This was carefully unfolded and repositioned in an oblique fashion along the inferior pole of the implant. There was no evidence of vascular ingrowth on this anterior surface. Neck irrigation was then performed and all fluid evacuated with Yankauer suction. Alloderm was tacked into its position using an initial three-way suture from the deep mastectomy flap edges down to the alloderm at the level of the areola. The remainder of the closure was performed using deep 3.o monocryl sutures followed by deep dermal 3.0 monocryl sutures and finally a running 4.o monocryl subcuticular stitch. Steri-strips and a medipore dressing were applied.
SuperCoder Answered Fri 28th of July, 2017 08:06:38 AM
As per the presented documentation, CPT code for revision of reconstructed breast including wound excision would be 19380.
For application of Alloderm, CPT code would be 15271
Note: To report each additional 25 sq cm wound surface area, report CPT code 15272.