Part 6: CPT Breast Education Series | Revision of Breast Reconstruction

Beth Martilik,​ MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador

This is Part 6 of a 6-part series focusing on CPT coding of breast procedures. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. Part 6 focuses on revision of a reconstructed breast.

Revision surgery on a reconstructed breast is designed to fine-tune the reconstruction in order to improve the overall cosmetic appearance. Some typical procedures that may be performed include adjustments to the inframammary crease, repositioning the breast, capsular adjustments, liposuction or fat grafting, trimming of excess skin, replacement of implant, and scar revision.

Please note that surgeons may use the term Revision when reconstruction has not been completed. For example, if the patient has a temporary tissue expander and has not undergone stage two with permanent implant placement, the reconstruction is not complete. For coding purposes, Revision refers to adjustments on an already reconstructed breast. Reconstruction is complete when a permanent implant is inserted, or an autologous flap has been inset. There should be nothing left to do except cosmetic adjustments later.

Code 19380 is used for the many procedures that may be done as part of a revision procedure after final reconstruction is complete. Separate codes would not be assigned for each component procedure. As an example, if a reconstructed breast has fullness that requires liposuction, the coder would not assign code 15877. The only code needed is 19380 for Revision of reconstructed breast.
Replacement of a permanent breast implant is not included in code 19380. If the patient is having a new implant inserted, perhaps to a different size, either code 19340 or 19342 can be assigned separately. The code will depend on whether the initial implant was an immediate or delayed insertion.

---

19380

Revision of reconstructed breast

---

 

This concludes this 6-part series on coding for breast reconstruction procedures. There are a limited number of codes available for these reconstruction procedures. Coders will need to be alert to slight differences in code descriptions that will affect code assignment, such as immediate versus delayed insertion, pedicle versus free flaps, or revision of reconstructed breast. Appropriate coding will require coders to correctly interpret the procedure performed.

References:
Coding Clinic for HCPCS, Third Quarter 2019: Page 13
CPT Assistant, December 2017, Volume 27, Issue 12, page 13
Coding Clinic for HCPCS, 4Q 2017, p 6
CPT Assistant, December 2015, Volume 25, Issue 12, page 18

 

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.