Op Note Coding Clinic: Breast Reconstruction with AlloDerm

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.

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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%…

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