Tag Archives: mastectomy
Posted on 15. Dec, 2009 by .
Question: Our surgeon performed a scar revision on the site of a previous mastectomy. The procedure involved excising a 16.5 cm curved scar before performing a layered closure. How should we code this?
Answer: You should use complex wound repair codes for the scar revision procedure that you describe. Specifically, you should use the trunk codes 13101 (Repair,complex, trunk; 2.6 cm to 7.5 cm) and +13102 (… each additional 5 cm or less [List separately in addition to code for primary procedure]).
Measure repair: Whether straight, curved, angular, or stellate, the operative report should note the length of the repair. Because your report stated 16.5 cm, you should report 13101 for the first 7.5cm and +13102 x 2 for the additional 9 cm.
You should not code separately for the scar excision. When the surgeon removes the scar, he creates the “defect” that he then repairs. The scar excision plus the layered closure justifies selecting the complex wound repair codes rather than intermediate wound repair.
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Posted on 29. Jul, 2009 by .
Question: We received a mastectomy specimen based on a prior cancerous biopsy but find no residual tumor. How should we code the mastectomy (procedure and diagnosis)?
Answer: The final diagnosis for a mastectomy specimen doesn’t change your procedure coding. You don’t mention lymph nodes, so you should report the pathologist’s mastectomy examination as 88307 (Level V –Surgical pathology, gross and microscopic examination, breast, mastectomy – partial/ simple), regardless of the final diagnosis.
Diagnosis coding rules require you to report the most specific diagnosis available at the time. Here’s 3 steps that ensure you do just that:
1.If you have the pathologist’s report and it includes a definitive diagnosis, you should use that diagnosis.
Posted on 01. Jul, 2009 by .
Surgeons now commonly use AlloDerm in a variety of surgeries, including breast reconstruction procedures. This product and the work associated with using it can present some unique coding challenges, and there are some big coding changes that take effect July 1.
Let our experts help you sort through some of the breast reconstruction surgery coding myths you might encounter. Uncover the truth about AlloDerm coding using this case study presented by Dolores D. Carey, CCS-P, physician-based coder for Loyola University Physician Foundation in Maywood, Ill.
Operative note: The surgeon performed a bilateral mastectomy. He created a submuscular pocket on the patient’s left side after achieving meticulous hemostasis and removing the pec inferiorly. He placed an implant — medium-height Contour Profile Mentor 275cc — into the pocket after achieving meticulous hemostasis. Next, the surgeon fashioned AlloDerm acellular dermis for the inferior pole in a standard fashion and sutured it in place with #2-0 PDS sutures after a fill of 120cc over a drain. He then performed the exact same procedure on the patient’s right side. Once satisfied, the surgeon placed the patient in a seated position and noted the implants were in good position related to her cleavage and inframammary fold. He placed the patient back in the supine position. He copiously irrigated the region using antibiotics solutions, placed drains, and closed.
Myth #1: Report 15330-15336 for Sling Placement
When your surgeon uses AlloDerm during breast reconstruction, you may think you should code 15330 (Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children), and then add +15331 (… each additional 100 sq cm, or each additional 1%…