Procedure Practice 11/15/99 - Coding Recommendations

Feature Article 11/15/99:

Reconstructive Breast Surgery

Cosmetic Procedures -Postmastectomy Breast Reconstruction
  

Reconstructive breast surgeries are performed for a variety of reasons. Surgery may be done to reduce or augment breast size or to reconstruct breast tissue after mastectomy or trauma. Reading through these procedures can be confusing even for experienced coders. This month we review some of the most frequently performed breast procedures and how to correctly code them.

Cosmetic Procedures

Reduction Mammoplasty

Breast reduction, or reduction mammoplasty, is a procedure performed for women with large, pendulous breasts. It may be done for purely cosmetic reasons to enhance appearance, or it may be considered medically necessary if the patient suffers from back and neck pain or restricted physical activity due to macromastia. The procedure removes fat, glandular tissue, and skin from the breasts making them smaller, lighter, and firmer.

Techniques for breast reduction vary, but the most common procedure involves an anchor-shaped incision that circles the areola, extends downward, and follows the natural curve of the crease beneath the breast. The surgeon removes excess glandular tissue, fat, and skin, and moves the nipple and areola into their new position. Then the skin from both sides of the breast is brought down and around the areola, shaping the new contour of the breast. Liposuction may be used to remove excess fat from the axillary area. In most cases, the nipple remains attached to its blood vessels and nerves. However, if the breast is very large or pendulous, the nipple and areola may have to be completely removed as a free graft and reattached to the breast in a higher position.

Assign CPT code 19318 for unilateral reduction mammoplasty. Add modifier -50 for bilateral reduction procedures. Assign CPT code 15200 for nipple grafting, or CPT code 19350 for nipple/areola reconstruction, if done. Select the appropriate ICD-9 procedure code from the 85.3x range. Do not assign an additional code for nipple transposition performed during the same operative episode, as it is considered an inherent component of the reduction procedure.

Reduction Mammoplasty for Gynecomastia

Gynecomastia is the presence of excessive fat and glandular tissue in male breasts. Surgery to reduce breast size is done via a circular incision in the skin of the breast at the edge of the areola or along the inframammary fold. The extra fat and breast tissue are dissected from the pectoralis fascia and removed. Bleeding vessels are ligated with sutures or electrocautery and the incision is closed in layers.

Assign CPT code 19140 and ICD-9 code 85.31 for breast reduction for gynecomastia. Bilateral reduction is coded 19140-50 and 85.32.

Breast Augmentation

Surgical augmentation of the breast is usually accomplished by using an artificial implant that is placed beneath the breast tissues. Implants are available in a variety of sizes. The implant itself consists of a silicone jacket filled with saline solution. During the procedure, the surgeon incises the breast along the inframammary fold and elevates breast tissue and the pectoralis muscle beneath the breast away from the chest wall. The implant is then positioned under the pectoralis muscle next to the chest wall. An alternative placement positions the implant just behind the breast tissue and on top of the pectoralis muscle. Incisions are repaired in a layered fashion.

Assign CPT code 19325 for unilateral breast augmentation with implant and code19325-50 for bilateral augmentation with implant. Unilateral breast augmentation with implant is coded to ICD-9 code 85.53. Assign code 85.54 for bilateral implant augmentation.

A less frequent breast augmentation procedure simply rearranges existing breast tissue without using an implant. The surgeon makes an incision along the inframammary fold, separates skin and subcutaneous tissue from breast tissue, and repositions the breast tissue. Redundant skin may be excised to give the breast a firmer appearance. Incisions are closed in layers.

CPT code 19324 is the correct code for unilateral breast augmentation without prosthesis, and 19324-50 is used to code a bilateral procedure. ICD-9 code 85.50 correctly identifies augmentation mammoplasty without an implant.

Mastopexy

Breast sagging (ptosis) is surgically corrected with a breast lift (mastopexy). During the two-hour operation, the surgeon moves the nipple and areola to a higher position and removes excess skin from beneath the breast. Closure of the remaining skin lifts the breast mound to a higher position and recontours the breast. If inadequate breast tissue exists to fill the skin and achieve the desired size, a saline-filled breast implant may be placed beneath the breast at the same time.

Assign CPT code 19316 for simple mastopexy without breast implant. Also assign code 19340 if an implant is inserted during the same operative session. The appropriate ICD-9 codes are 85.6 for mastopexy without implant and 85.6 with 85.53 if an implant is used.

Postmastectomy Breast Reconstruction

Tissue Expander and Implant

This multi-stage procedure may begin immediately following mastectomy during the same operative session, or it may be delayed for months or years after mastectomy surgery. In either case, the stages of the procedure are the same. In the first stage, the surgeon selects an appropriate size tissue expander and creates a pocket under the pectoralis muscle of the chest to house the tissue expander balloon. Once the pocket has been created, air is removed from the expander and the balloon is tested for leaks with saline solution. The balloon is then filled with 50 to 100 cc of saline and inserted into the muscle pocket. At the end of the procedure, the muscle and skin are loosely closed, and a Jackson Pratt drain is placed into the wound and sutured to the skin for postoperative drainage.

Both the immediate and the delayed insertion of a tissue expander are assigned CPT code 19357 and ICD-9 code 85.95.

The expansion phase of this procedure begins approximately two weeks postoperatively. During weekly office visits, the surgeon gradually increases the size of the expander balloon by injecting measured amounts of saline solution into it, generally from 50 cc to 200 cc total volume. As the balloon increases in size, the tissue also expands until the desired breast size is achieved. CPT code 19357 includes subsequent expansions of the balloon, so no additional CPT surgery code would be assigned for expansion visits.

Assign ICD-9 code 85.51 for each expansion procedure.

The final stage of the procedure during which the expander is exchanged for a breast implant occurs approximately four months after expansion is complete. During this final stage, the patient returns to the operating room where the breast is reopened at the previous incision site, the tissue expander is removed, and a saline implant is placed.

Assign CPT code 11970 and ICD codes 85.53 and 85.96 for removal of a breast tissue expander with placement of a permanent implant.

TRAM Flaps

This type of breast reconstruction may be done immediately following mastectomy or it may be delayed following completion of all adjuvant cancer therapies. The transverse rectus abdominis myocutaneous flap (TRAM) uses the patient's own abdominal wall fat with a muscular and vascular pedicle. Several variations of this procedure exist.

In the single pedicle TRAM flap procedure, the surgeon first marks and cuts a skin island flap on the lower abdominal wall, generally below the umbilicus. Then a flap of skin and fat is raised off the rectus abdominis muscle. A transverse incision is then made in the rectus sheath and the muscle is divided, taking care to protect the blood supply to the flap. The flap remains attached via a single superior pedicle of the rectus abdominis muscle with preservation of its superior epigastric arterial supply. Once the muscle is raised, the surgeon makes an incision in the chest skin and creates a pocket for the muscle flap. A connecting tunnel is created under the elevated chest skin and the donor flap. The flap is passed up through the tunnel to the chest, placed in its new position, contoured and sutured to the chest wall fascia. The mastectomy skin flaps are attached to the TRAM flap and drains are sutured into place. The abdominal wall is reapproximated by suturing the remaining anterior rectus muscle to the remaining lateral muscle. The fascial defect left by harvesting the rectus abdominis muscle may be reconstructed with a strip of marlex mesh sutured to the surrounding anterior abdominal wall fascia. Skin edges are sutured in layers over the muscle. Multiple suction drains are placed in the abdomen and anchored to the skin to allow for postoperative drainage.

Assign CPT code 19367 and ICD-9-CM code 85.7 for this procedure.

TRAM flaps may be done with a double pedicle to provide additional blood flow to the flap and improve likelihood of long-term flap viability.

Assign CPT code 19369 for a double pedicle TRAM procedure; the ICD procedure code remains 85.7.

Because of the potential for partial or even complete necrosis of the TRAM flap as a result of poor vascularization, a third version of this procedure has been developed. In this variation, sometimes referred to as a "supercharged TRAM flap," the surgeon creates additional blood flow to the flap via microvascular anastomosis of blood vessels from the axillary and internal mammary vascular systems to the flap.

The correct CPT code for a supercharged TRAM procedure is 19368. Assign ICD-9 code 85.7 for this procedure.

TRAM Flap Revision/Contouring

Approximately four to six months after initial reconstruction, the TRAM flap may require contouring revisions. These revisions may be performed by direct excision of tissue or by using liposuction to contour the breast mound. Assign CPT code 19380 and ICD-9 code 85.89 for TRAM flap revision.
  

Latissimus Dorsi Myocutaneous Transposition Flap and Implant

This method may also be used for either immediate or delayed breast reconstruction. The procedure is similar to a TRAM flap in that it uses autogenous tissue to create a new breast. However, in addition to the tissue transfer, an implant may be needed to achieve appropriate size. The surgeon harvests tissue from the back by making an incision through the skin and latissimus dorsi muscle and rotating the resulting flap to the front of the chest via a tunnel beneath the axillary skin. As in the TRAM procedure, the muscle flap remains attached to its blood supply via a pedicle. The flap is brought up through the mastectomy incision, contoured, positioned, and then sutured to the surrounding muscle, chest wall, and skin. The back incision is closed in layers and drains are used for postoperative drainage both at the mastectomy and donor sites.

Assign CPT code 19361 for this procedure (both with and without the use of an implant) and ICD-9 code 85.85 for graft only reconstruction. If an implant is needed, also assign ICD-9 code 85.53.

Free Tissue Transfer

Free tissue grafts may be used for immediate or delayed breast reconstruction following mastectomy. In this procedure, the tissue flap is completely removed from the donor site along with its supplying artery and vein. TRAM flaps (minus their pedicles) are the most commonly used donor sites, however a gluteal free flap using portions of the gluteus maximus is sometimes used. The free graft consists of skin, fat, and muscle tissue that is dissected from the donor site and transferred to the mastectomy site on the chest wall. Microvascular anastomosis is required to attach the arteries and veins of the flap to new vascular sources within the chest wall. The flap vessels are generally connected to the thoracodorsal artery and vein within the axilla, or to the internal mammary artery and vein. This procedure involves increased operating time and greater risk of complete flap loss due to inadequate blood supply.

Assign CPT code 19364 for free flap graft breast reconstruction. This code includes flap harvesting, donor closure, microvascular anastomosis, and shaping of the flap. The correct ICD-9 procedure code is 85.85.

Nipple/Areola Reconstruction

Once the breast mound has been recreated with one of the above techniques, nipple/areola reconstruction can be performed. To reconstruct the areola, a full thickness skin graft is harvested from the inner thigh area or behind the ear. To create a new nipple, the surgeon may transplant a portion of the nipple in the remaining breast, or donor tissue may be harvested from the ear or labia. A thin circular layer of epithelium is removed from the reconstructed breast at the site of the graft. The areola skin graft is positioned and sutured to the breast, and the nipple graft is then sutured to a small, circular incision made in the new areola's center.

Assign CPT code 19350 for nipple and areola reconstruction. Select ICD-9 code 85.86 if a nipple or portion of a nipple was surgically moved (as in using nipple tissue from the remaining breast), or use code 85.87 for nipple reconstruction using tissue from other donor sites.

Practice Makes Perfect!

Are you ready for some hands-on practice?

Read the patient report(s) on our procedure practice page. Assign the appropriate codes and then compare your answers with our coding recommendations. Good luck!

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