Awesome tips for Mastectomy coding (mastectomy reconstruction, partial and total mastectomy)


According to CPT , you should report partial mastectomy procedures using 19301 or 19302 as appropriate. Documentation for partial procedures should include attention to the removal of adequate surgical margins surrounding the breast mass or lesion. In addition, total mastectomy procedures include simple mastectomy, complete mastectomy, subcutaneous mastectomy, modified radical mastectomy, and more extended procedures (for example, an Urban type operation).
These tips are really important for Certification exams like CPC, you can go through sample CPC questions here which will surely help in clearing CPC exam.

 Read also : Superb tips for coding Follow-up visit ICD 10 codes

Here's a full list of the CPT codes you'll need when reporting mastectomy procedures:

·         19300 -- Mastectomy for gynecomastia
·         19301 -- Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy)
19302 -- ... with axillary lymphadenectomy
19303 -- Mastectomy, simple, complete
19304 -- Mastectomy, subcutaneous
19305 -- Mastectomy, radical, including pectoral muscles, axillary lymph nodes
19306 -- Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)
19307 -- Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle.

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During breast procedures, if the surgeon removes a lesion along with a significant portion of surrounding tissue, you should choose a partial mastectomy code. If the surgeon removes only the lesion and a small portion of surrounding tissue, an excision code is probably more appropriate.
Here are four rules that can help guide you through the decision process:

Rule 1: Consider Intent to Obtain Margins

As a general guideline, if the surgeon removes a breast lesion along with a margin of healthy tissue, you can choose the partial mastectomy code (19301) to describe the procedure. In this case, the surgeon usually assumes that the mass is malignant.

Don't get hung up on measurements: There is no specific requirement in CPT or CMS regulations that says the margin must be of a specific size (for instance, 1 cm or more) to qualify as a partial mastectomy. Rather, the margins must only be "adequate" to ensure that the surgeon removes possible malignant tissue surrounding the excised mass. Despite a surgeon's best effort to clear a lesion with margins, he may not get 1 cm but still could have performed a segmental mastectomy.

Documentation matters: The physician has to put in his operative report that he paid special attention to the surgical margins. You cannot claim 19301 without documentation of margin removal.

Minimal margins call for 19120: Use the excision code 19120 (Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19300], open, male or female, one or more lesions) if the surgeon removes only the tumor and no or very little margin. The lump is likely fairly small and clearly defined, and the surgeon assumes the tumor is not malignant in such a case.

Watch for "staged" procedures:
If the surgeon removes only the lesion with minimal margins (19120), but the pathology report reveals malignancy, the surgeon must return the patient to the operating room and remove additional tissue. In this case, you may report the follow-up procedure using the partial mastectomy code 19301 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.

Because the results of the first excision led to the decision to perform the partial mastectomy, you should report both procedures separately, according to CMS guidelines outlined in the Correct Coding Initiative (CCI) and elsewhere.

Rule 2: 25 Percent Ensures 19301

The term "quadrantectomy" (which means removal of one quarter of the breast tissue) in 19301's definition means that you can safely choose 19301 instead of 19120 if the surgeon removes at least a quarter of the breast tissue. Note, however, that CPT does not explicitly define when a simple excision crosses the line to become a partial mastectomy. In other words, removing 25 percent of the breast tissue definitely qualifies as a partial mastectomy, but CPT does not prohibit reporting 19301 for removal of 20 percent of the breast tissue, for instance -- as long as the surgeon takes adequate margins when removing the breast mass.

A surgeon under these conditions has to be aware of the cancer's location and take enough tissue to get good margins. If the surgeon's intent during surgery is to remove a lesion with margins, you should choose 19301.

Rule 3: Watch for Lymph Node Excision

Often, with partial mastectomy, the surgeon performs an axillary lymphadenectomy to remove the lymph nodes between the pectoralis major and the pectoralis minor muscles. The surgeon may also remove the nodes in the axilla through a separate incision at the same time. In such cases, you should report 19302 for the combined procedure rather than reporting 19301 and 38745 (Axillary lymphadenectomy; complete) separately.

Beware "staged" exception: The surgeon may return during the postoperative period to see if there has been any lymph node involvement and, if so, may choose to remove the nodes following some partial mastectomies (19301). In such a case, report the lymphadenectomy as a staged procedure using 38745 with modifier 58 appended.

Rule 4: Don't Rely on 'Lumpectomy'

You shouldn't base your code choice on the term "lumpectomy" in the surgeon's documentation. Technically, lumpectomy describes excision of a small, intact tumor, whether cancerous, precancerous, or fibroid -- but physicians often use the term to describe any excision of breast tissue, regardless of size.

Although "lumpectomy" appears in 19301's descriptor, either 19120 or 19301 could apply, depending on exactly what the surgeon did. The CPT descriptor for 19301 also includes the terms "tylectomy" and "segmentectomy," but these terms only serve to confuse. Tylectomy and segmentectomy can technically be identical or each one different. The definitions are subjective.

Best advice: You are much better off choosing a code based on the surgeon's effort to obtain margins around the excised mass rather than according to the terminology the surgeon uses to describe the procedure.

Use Modifier 22 for Skin-Sparing Mastectomies

The skin-sparing mastectomy is a coding challenge you may encounter because there currently isn't a code for the procedure. The skin-sparing mastectomy takes much longer than the traditional mastectomy and achieves a better cosmetic result.

For accurate billing, attach modifier 22 (Increased procedural services) to the mastectomy code that is appropriate. The physician should also fully document the additional work and time involved in this procedure. Time is a factor in skin-sparing mastectomies, and you can use modifier 22 successfully to prove the procedure took longer to perform than a standard mastectomy. If necessary, use the anesthesia record in your appeal. The anesthesia record is the only real-time documentation of what went on during the procedure.

Breast Reconstructions Have Their Own Coding Rules
The surgeon may perform breast reconstruction procedures following cancer, infection, trauma, or burns, or in some cases, strictly for cosmetic reasons. Applicable codes include:

·         19316 -- Mastopexy
19318 -- Reduction mammaplasty
19324 -- Mammaplasty, augmentation; without prosthetic implant
19325 -- ... with prosthetic implant
19328 -- Removal of intact mammary implant
19330 -- Removal of mammary implant material
19340 -- Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19342 -- Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19350 -- Nipple/areola reconstruction
19355 -- Correction of inverted nipples
19357 -- Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19366 -- Breast reconstruction with other technique
19370 -- Open periprosthetic capsulotomy, breast
19371 -- Periprosthetic capsulectomy, breast
19380 -- Revision of reconstructed breast.

You should report 19316 for mastopexy procedures, also known as breast lifts. Although your surgeon may perform this for cosmetic reasons, some insurers cover mastopexy when the surgeon performs a full reconstruction on one breast (for example, following cancer) and then performs mastopexy on the healthy breast to make it look like the reconstructed breast.

Surgeons may perform mammaplasty for breast reduction or for augmentation (implants). You should report 19318 for breast reduction. You may find this service payable when patients require a reduction for medically necessary reasons, such as intertrigo (695.89), which is a fungal infection under the breast. In addition, insurers may reimburse reduction mammaplasty for a history of back pain or when the surgeon must remove more than 500 grams from the breast.

If the surgeon performs an augmentation, you'll want to consider 19324 and 19325, depending on whether he uses a prosthetic implant.

If the surgeon performs nipple or areola reconstruction, you'll report 19350. The surgeon usually takes the skin from the inner thigh or from behind the ear to form the nipple. The donor site repairs are generally considered separate repairs, as in the case of grafting. When the donor site requires a separate repair, you can report it separately.

When your surgeon performs a reconstruction using a tissue expander, you'll report 19357. During this procedure, the surgeon places a flat, balloon-like device through an incision and then slowly over time inflates it.

Keep in mind: The descriptor for 19357 states, "including subsequent expansion." Therefore, you cannot separately bill the insurer when the patient returns for gradual expansion. Surgeons usually fill the expander until the size is suitable for an implant insertion.
Following breast augmentation, the patient may develop a capsule or scar tissue that can cause pain. The surgeon may perform a capsulectomy to treat this condition. During the surgery, the physician removes the capsule and the implant. You should report 19371 for the capsulectomy, and if the surgeon inserts a new implant following the capsulectomy, you should report 19340.

Separate 19371 and 19340: Surgeons usually don't perform capsulectomy and implant reinsertion through the same incision, which is why you should report 19371 and 19340 separately. Although the surgeon treats the same breast, he has to perform dissection of a new pocket, often in a different plane. Because of the separate sites, correct coding demands that you report both 19371 and 19340.

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