Cheryl Posted Thu 08th of August, 2019 09:45:27 AM
Patient had undergone bilateral 2nd stage breast reconstruction with placement of silicone gel implants. Several days later Pt was doing a stretching exercise and the right breast incision opened spontaneously. Pt brought back to the OR with a 5.5cm opening and implant visualized. Implant removed, wound edges sharply debrided and then a new implant was placed. No infection had occurred. Reviewing CPT 19380 for this procedure. Thank you.
SuperCoder Answered Fri 09th of August, 2019 06:14:04 AM
In CPT 19380, the revision is done on a reconstructed breast, usually to correct a problem with asymmetry, but other cause also can be considered. 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. In this situation, the CPT 19380 is appropriate to code for the condition.
On the other hand, if this procedure (19380) is under global period of previous surgery, then append modifier 78 (Unplanned Return to the Operating). Modifier 78 is for unplanned procedure that requires the patient to return to the operating room. The unplanned procedure is related to an initial procedure. The provider performs the unplanned procedure during the initial procedure’s postoperative period.
Hope this helps!