This is Part 2 of a series on coding breast diagnoses and procedures. Part 1, which detailed breast related diagnoses and diagnostic procedures, can be found on our Web site at: www.advanceweb.com/him. This month's article will focus on appropriate coding for mastectomy procedures with various reconstructive techniques and breast implant procedures.
As noted in Part 1, the coder should ensure that the specific quadrant of the breast is specified and coded to the most specific level of detail. Each operative report should be reviewed in its entirety to ensure that the techniques documented in the body of the report match and support the title of the procedure initially planned. These complex therapeutic breast procedures should never be coded without an operative report. There are too many similar but very different procedures that fall under the same general category, such as "mastectomy."
The term "mastectomy" is a broad one, and includes any therapeutic excisions of breast tissue. However, there are many different mastectomy techniques; the coder must be able to determine both the extent of the excision and whether or which reconstructive techniques were provided to assign mastectomy codes appropriately.
Listed below are the most commonly performed mastectomy procedures and their corresponding codes:
Partial Mastectomy (Lumpectomy)
A lesion or mass is excised from the breast, along with a margin or rim of healthy tissue, which is called "attention to adequate surgical margins." The operative report must contain documentation of this attention to margins; the diagnosis is most frequently a malignant tumor. Physician documentation of the title of this procedure can vary significantly; a partial mastectomy may also be known as a lumpectomy, quadrantectomy or segmental mastectomy. The mastectomy CPT codes were renumbered and reordered for 2007. Assign CPT code 19301, Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy) for a partial mastectomy procedure. Code 19302 should be assigned if the procedure includes excision of axillary lymph nodes (between the pectoralis major and pectoralis minor muscles and the nodes in the axilla) via a separate incision. It's important to note that CPT codes typically provide combination codes that include both the mastectomy procedure and any related lymph node excision. The ICD-9-CM procedure coding guidelines don't provide combination codes, so for the lumpectomy mastectomy procedure, both codes 85.23, Subtotal mastectomy, and 40.23, Axillary node excision, should be assigned if the service is provided on an inpatient basis.
Simple Complete Mastectomy
This procedure includes removal of all breast tissue, along with a portion of skin and nipple through an elliptical incision. The documentation may include mention of a "modified" simple mastectomy, which may spare the skin and nipple, but all subcutaneous breast tissue is excised via a dissection of breast tissue from the pectoral fascia and sternum. Assign CPT code 19303 Mastectomy, simple, complete for this procedure; ICD-9-CM code 85.41 should be assigned for an inpatient visit.
This mastectomy procedure is similar to the simple complete mastectomy except that the extent of the excision is different. For a subcutaneous mastectomy the breast is dissected from the pectoral fascia and from the skin. The breast tissue is removed, but the skin and pectoral fascia remain. The coder must carefully review the operative report for documentation of the extent of excision. Assign CPT code 19304 Mastectomy, subcutaneous for this procedure. The ICD-9-CM procedure codes are differentiated by:
a) whether the procedure was performed unilaterally or bilaterally, and
b) whether an implant was inserted at the same surgical episode.
Codes 85.33, 85.34, 85.35 and 85.36 represent subcutaneous mastectomy procedures.
Radical and Modified Radical Mastectomy
The most extensive of the mastectomy procedures, the radical mastectomy, involves dissection of the breast, overlying skin, the pectoralis major and minor muscles and the axillary lymph nodes, which are all removed as a single specimen. Assign CPT code 19305 for this service. If the documentation indicates that both axillary and internal mammary lymph nodes were excised, then this is considered an Urban type procedure and code 19306 should be assigned instead. In some cases, closure may require skin grafts or myocutaneous flaps. In a modified radical mastectomy, the structures listed above are excised, but the pectoralis major muscle (and possibly the pectoralis minor muscle) are spared. Assign CPT code 19307 for a modified radical mastectomy. Note that ICD-9-CM classifies radical and modified radical mastectomies somewhat differently. Assign code 85.45 or 85.46 respectively, for a unilateral or bilateral radical mastectomy. An Urban type of complex mastectomy with more than regional lymph node excision is considered an "extended radical mastectomy" and should be assigned to code 85.47 (unilateral) or 85.48 (bilateral). A modified radical mastectomy is considered an "extended simple mastectomy" and should be assigned to code 85.43 (unilateral) or 85.44 (bilateral).
Breast Prosthesis Insertions
Each of the mastectomy codes in CPT contain instructional notes related to breast implant insertion procedures that are performed at the same surgical episode as the mastectomy, as well as those inserted at a later date. Assign CPT code 19340 if the insertion was performed at the same surgical session; code 19342 is assigned if the insertion was performed at a later date. Note that these codes are not restricted only to mastectomy procedures. They may be assigned when a patient has undergone mastopexy or a reconstructive breast procedure as well.
Breast reconstructive procedures are commonly performed at the time of mastectomy, or shortly thereafter. Various techniques are available and are selected based upon the patient's diagnosis, anatomy and preference. A few of the more common reconstructive procedures are discussed below.
Breast Reconstruction With or Without Tissue Expander
After a patient has undergone a mastectomy, a pocket is created using an existing chest wall muscle and an expandable implant is placed, into which the physician injects saline through a portal. In some cases this prosthesis remains permanently and in other cases a second surgery is required to remove the implant and replace it with a permanent breast prosthesis.
Latissimus Dorsi Flap Breast Reconstruction
For this procedure the physician dissects a portion of the latissimus muscle from the patient's back; the muscle-skin flap remains attached to a main artery and is then rotated to the front of the chest through a tunnel under the patient's armpit so that it extends through to the mastectomy incision. It's attached to the chest wall and adjacent muscles for the most aesthetic appearance. Assign CPT code 19361 for this procedure and if an implant is also inserted, add code 19340. For ICD-9-CM coding, assign 85.85 for a muscle flap graft to breast.
Transverse Rectus Abdominis Myocutaneous Flap (TRAM) Breast Reconstruction
This procedure also represents a muscle/skin flap transfer in which the rectus abdominis muscle is divided, but kept attached to its blood supply. It is passed through a connecting tunnel between the elevated chest skin and the inferiorly positioned flap. The muscle is contoured to make a breast mound. Report CPT code 19367 if only one pedicle flap is documented. If additional microvascular anastomosis for connecting blood vessels is provided, assign instead code 19368. If the documentation includes mention of the muscle/skin complex having two pedicles or both sides of the rectus abdominis are elevated (bilateral or hemiflaps), assign code 19369. Assign ICD-9-CM procedure code 85.7 for this procedure.
Free Flap Breast Reconstruction
A breast reconstruction with the use of a free flap involves excision of a completely free flap of skin, fat and muscle from another site on the patient, typically the thigh or buttocks. The excision includes careful dissection of vascular channels, which are anastomosed or attached to the mastectomy site via a microvascular technique to ensure a viable blood supply. Assign CPT code 19364 or ICD-9-CM code 85.7 for this procedure.
After reconstructive breast surgery procedures, it's sometimes necessary to return for further surgery related to the previous procedure, particularly if an implant is involved. The following procedures represent some of the most common additional procedures.
Removal of Intact Mammary Implant
A breast implant may require removal for a number of reasons, including infection, displacement, excessive capsule formation or pain. When the implant is considered intact, has not ruptured and can be removed in one piece, assign CPT code 19328 and add code 19340 if another implant is placed at the same surgical episode. ICD-9-CM code 85.94 should be assigned for this procedure.
Removal of Mammary Implant Material
When a breast implant is not intact and has leaked or the material has otherwise migrated from its original location, it may require removal by a piecemeal approach. An incision is made and the implant material is carefully dissected out. Assign CPT code 19330 for this procedure and add code 19340 if another implant is placed. The same ICD-9-CM procedure code is assigned for this procedure: 85.94. If another unilateral implant is placed, add code 85.53. Note that code 85.93 Revision of implant of breast, should only be assigned if a surgical correction or adjustment of the original implant is performed.
Periprosthetic Breast Capsulotomy
In some cases after breast implantation, an extensive capsule is formed around the implant, which involves a dense membranous structure that may be contracted and cause pain or other complications. In a capsulotomy procedure, an incision is made around the capsule's circumference, which enlarges the pocket and relieves the tightness and pain. No tissue is removed in this procedure and CPT code 19370 should be assigned. If performed in the inpatient setting, ICD-9-CM code 85.0 should be assigned.
Periprosthetic Breast Capsulectomy
The fibrous breast implant capsule may progress to a point in which the decision is made to remove it, along with the scarred tissue. In a capsulectomy procedure, a circumferential incision is made around the implant, the contracted capsule is excised from the breast tissue and the prosthesis is removed. Report CPT code 19371 for this service and ICD-9-CM codes 85.20 and 85.94 for the implant removal.
Breast Reconstruction Revision
In some cases, a reconstructed breast may require some revision, most commonly for asymmetry. An incision is made and the tissues may be rearranged or secured with sutures to revise the shape of the breast. The existing implant may be replaced and excess skin or tissue may be removed. Report CPT code 19380 for this procedure. Assign ICD-9-CM code 85.89 and add code 85.93 if the implant is revised.
Chest Wall Tumor Procedures
Some breast cancer patients have tumor recurrence after their mastectomy and it's especially important that the coder determine the exact site of the neoplasm. If no breast tissue remains, the tumor may actually involve the chest wall and should be coded accordingly. The physician may document "breast carcinoma" or "breast metastasis," but he or she may be referring to the cell type, not to the site of the neoplasm. Excisions of chest wall tumors are reported with CPT codes 19260, which includes rib excision, 19271, which includes plastic reconstruction but no mediastinal lymphadenectomy, and 19272, which includes plastic reconstruction and mediastinal lymphadenectomy.
As a last reminder, coders should assign modifier RT (right side), LT (left side) or 50 (bilateral procedure) to all breast procedure CPT codes to ensure appropriate specificity. As with all CPT coding, coders should review any and all CCI edits and apply modifier 59 when appropriate. When assigning ICD-9-CM procedure codes, the coder should carefully review the code terminology for reference to unilateral or bilateral and assign the most accurate code.
Review your skills in coding breast therapeutic procedures with the following quiz:
1. A female patient with a history of breast cancer with past reconstruction and implant presents with severe pain in and around the reconstructed left breast. She was taken to surgery and a breast capsulotomy was performed without removal of the implant. Assign the appropriate CPT and ICD-9-CM procedure codes:
a. 19371-LT, 85.21
b. 19370-LT, 85.0
c. 19380-LT, 85.0
d. 19328-LT, 85.93
2. A 39-year-old female patient with biopsy-proven breast carcinoma was seen for follow-up procedure. She was taken to the operating room, where a lumpectomy of the right breast was performed, with adequate surgical margins around the tumor area. Assign the CPT and ICD-9-CM procedure codes:
a. 19301-LT, 85.21
b. 19304-RT, 85.23
c. 19301-RT, 85.23, 40.23
d. 19301-RT, 85.23
3. A 47-year-old female patient was seen for right breast re-constructive surgery. The physician elected to perform a TRAM flap, whereby rectus abdominis muscle was detached from its initial location in the abdomen and passed through a subcutaneous tunnel to the chest wall. The procedure was documented as "supercharged" and an additional artery was anastomosed using microvascular techniques. Assign the appropriate CPT and ICD-9-CM procedure codes:
a. 19368-RT, 69990, 85.7
b. 19367-RT, 85.7
c. 19366-RT, 85.99
d. 19368-RT, 85.7
Coding Clinic is published quarterly by the AHA. CPT is a registered trademark of the AMA.
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix, which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Answers to CCS PREP!: 1. b. The procedure involved a breast capsulotomy (incision only), without removal of the implant. The most appropriate CPT code is 19370. Because there is no specific capsulotomy code in ICD-9-CM, assign code 85.0 for mastotomy; 2. d. The physician indicated that the patient had biopsy-proven breast cancer and the lumpectomy procedure involved a wide excision with attention to surgical margins. This is considered a partial mastectomy. CPT code 19301 should be assigned with modifier RT for right breast. ICD-9-CM code 85.23 is most appropriate for subtotal mastectomy and because no additional node procedure was performed, none should be coded; 3. d. The specific technique used for this breast reconstruction was a TRAM flap and the documentation included "supercharged" with microvascular anastomosis. CPT code 19368 is the most appropriate for this procedure, along with modifier RT for right breast service. There is an instructional note under code 19368 that indicates that code 69990 should NOT be reported in addition to 19368. ICD-9-CM code 85.7 is the most appropriate for total reconstruction of breast.