Part 1: CPT Breast Education Series - Overview of Breast Reconstruction

This is Part 1 of a 6-part series focusing on CPT coding of reconstructive procedures following mastectomy.  There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders.  Part 1 is an overview of the types of breast reconstruction techniques commonly used.  Future topics in this series will go into more detail of each technique and the CPT coding implications.
Following a mastectomy, a patient may choose to have a reconstruction procedure to restore the breast to near normal shape, appearance, symmetry and size.  Reconstruction can start as soon as the breast is removed by mastectomy or be delayed until a later date.  Breast reconstruction generally falls into two categories:  implant reconstruction or autologous tissue reconstruction.
If a breast cancer can be removed without taking away too much skin, a saline or silicone gel breast implant may be inserted under or in front of the pectoralis muscle. Inserting the implant under the muscle helps to keep the prosthesis in the right place and hide its outline.  Tissue expanders may be necessary when there is insufficient skin left on the chest following mastectomy to comfortably cover and support an implant.  Once the skin has stretched sufficiently the tissue expander can be replaced with a permanent breast implant.

A common reconstruction technique uses autologous flaps of the patient’s own tissue (with or without an implant), including the skin, fat and sometimes muscle. The flap can be taken from the back or lower abdomen, or from the inner thigh or buttock. This is then reshaped to form the new breast.

Once a reconstruction is complete, patients may undergo revision surgery to correct or enhance the appearance of the affected breast.  Revisions may be done for cosmetic reasons to improve the look or feel of the breast.  Adverse effects of the reconstruction, such as pain or scarring, can also be addressed with revision surgery.

Part 2 of this series will discuss coding for the use of tissue expanders in breast reconstruction.

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P


The information contained in this series is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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