Basics of Surgical Reconstruction of the Breast

After a patient has been diagnosed with breast cancer, the next process is weighing the surgical and medical options for treating the disease. The physician will discuss with the patient the best treatment options depending on the type of breast cancer, the stage, the size, sensitivity to hormones, and if it has metastasized.

Treatment options are considered based on the stage and may consist of surgical options such as excision of a breast lesion (CPT code 19120, 19125), lumpectomy (19301-19302), and mastectomy (19303, 19305. A 19125 is performed to remove abnormal breast tissue or lumps such as cysts or tumors. In CPT code 19301, the surgeon removes a single lump or portion of the breast tissue; whereas in a 19302, a single lump or portion of the breast tissue is removed and lymph nodes between the pectoralis major and minor muscles and in the axilla are removed through a separate incision. A 19303 is a simple, complete surgery to remove the entire breast or both breasts (double mastectomy); and a 19305 is a radical mastectomy — removal of breasts, underarm lymph nodes, and chest muscles.

Lumpectomy

Lumpectomy is also termed partial mastectomy and is the complete surgical removal of a primary tumor, but not a complete removal of the breast. Types of lumpectomy procedures are excisional biopsy, wide local excision, and re-excision lumpectomy. The key to reporting a lumpectomy procedure is understanding how much tissue is being excised or removed.

Codes 19120 and 19301 can often be confused. The key to choosing the correct code is the intent of the procedure, the tissue involved, and the diagnosis. Cancer is not always a reason to go right to a 19301. Consider what is being excised; for example, with 19301, the surgeon will take a margin or rim of healthy tissue. The intent, of course, is to capture the mass within the breast tissue at the area of concern, but removal of additional structures may be required. If the intent is to remove the lump and the lymph nodes between the pectoralis major and the pectoralis minor muscles, in addition to the nodes in the axilla, this would be a complete axillary lymph excision, reported with 19302.

In many cases, the surgeon may not take the full axillary chain and just remove some of the axillary lymph nodes. Instead of utilizing a modifier, the appropriate step is to utilize additional CPT codes to describe this work; 38500 and 38525  describe the extra work  of excising the lymph nodes during a partial mastectomy without removing the full chain.

In cases where cancer is advanced, radiation therapy after a partial mastectomy may be utilized. Codes are assigned as add-on services to 19301 and 19302 for the placement of radiotherapy after loading expandable catheters, which includes imaging guidance either on the day of the procedure (19297) or on a separate day (19296). The surgeon will work with the radiation oncologist as the radiation is delivered at a frequency of twice daily for five to seven days, depending on the type of cancer.

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Mastectomy

Mastectomy (simple or complete) involves the complete removal of all breast tissue. Types of mastectomy procedures are total mastectomy, double mastectomy, nipple-sparing mastectomy, and radical mastectomy. A complete mastectomy involves the entire breast and not just a lump and surrounding tissue. The nipple can be spared and preserved to use later in reconstruction. A radical mastectomy involves taking margins for removal of surrounding muscle tissue and nearby lymph nodes. What the surgeon takes will differ and necessitate use of various code options, so attention to detail and a clear understanding of anatomy are key when coding these procedures.

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Surgical Reconstruction of the Breast

After a patient receives surgical treatment, breast reconstruction may be needed to restore shape to the post-surgical breast. Reconstruction can be done at the time of a mastectomy or afterward. A breast surgeon can perform a skin-sparing mastectomy to save as much skin as possible for the reconstruction phase. Reconstruction may be done in two stages: First a tissue expander is placed that will be filled with saline at various visits post-mastectomy.
Then, with hopefully enough healing taking place, the second stage is to remove the expander and insert the implant. There are many ways  to reconstruct a breast using flaps and grafts from various anatomical sites on the body such as the abdomen, back, thigh, or buttocks. The challenge with these procedures from a billing standpoint is that many insurances may view them as cosmetic and deny coverage. Clear documentation showing medical necessity is crucial not only for prior authorization but also to stand up to an appeal if a denial takes place. To obtain proper reimbursement, review the Women’s Health and Cancer Rights Act of 1998 (WHCRA) for breast cancer patients.

Under this law, coverage must be provided for:
• All stages of reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.
This law applies to group health plans (provided by an employer or union) and individual health insurance policies (not based on employment).
Coding requires you to first determine what is being ordered, the reason, and what additional procedures are being performed at that time that may be bundled or included in the service. Common reconstructive procedures and ancillary services that are separately reportable include the following:

19361 Breast reconstruction; with latissimus dorsi flap

A surgeon will utilize tissue expanders, implants, skin or muscle flaps, and other reconstructive devices to reconstruct a breast after mastectomy. Additional procedures may be needed to achieve the desired size or shape. The reconstruction will utilize a latissimus dorsi flap. This involves a transfer of skin and muscle from the patient’s back to their affected breast to correct the defect created by the mastectomy, typically a radical procedure when the cancer was the reason for the mastectomy. It’s called a latissimus dorsi flap because the muscle and skin are taken from nearby structures. The flap under the armpit is rotated so that it can cover the mastectomy site.

Read also: Coding rules for Modifier 79, 78 and 58

Guidelines allow for separate reporting of a breast implant or tissue expander with the reconstruction, as necessary.
This is currently an inpatient-only code per the inpatient code list provided by the Centers for Medicare & Medicaid Services (CMS). Similar services include CPT 19364, 19367, 19368, and 19369.

19380 Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)

This code is utilized to reconstruct a breast or nipple after a mastectomy. Included in this code are tissue expanders, implants, skin or muscle flaps, and other reconstructive devices, when performed.
There may be ancillary procedures performed and billed to allow for a desired size or shape. It’s important that the medical necessity criteria are met for this procedure. Payers may consider this procedure cosmetic, and they also may have a yearly limit on how many times this procedure can be performed.

19318 Breast reduction

This is also referred to as a reduction mammoplasty. While this can be done for cosmetic purposes, there are medically necessary reasons to perform the procedure and various policies that need to be consulted for coverage criteria. Make sure that documentation includes all the required information to support medical necessity.

Physicians will typically document breast hypertrophy or an increase in the volume and weight of breast tissue as it relates to the general body habitus. This condition can affect other body systems such as musculoskeletal, respiratory, and integumentary. When one-sided hypertrophy exists, it may result in symptoms on the contralateral side where the mastectomy took place. The amount of tissue that must be removed to relieve symptoms will vary and depend upon such things as height, weight, and breast size.

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The Schnur Sliding Scale method is generally used to evaluate the need for a reduction. If the patient’s combined body surface area and weight of breast tissue falls above the 22nd percentile, then surgery is considered medically necessary. To receive approval from the insurance provider, you will usually need to provide pre-op photos to confirm this evaluation. Documentation is key.

19328 Removal of intact breast implant

Last year, breast reconstruction CPT codes underwent a major revision, 19328 included. The reason to perform a breast implant removal for medical necessity is due to infection or an abscess. The physician may state the procedure will be for the “removal of a breast implant with washout.” This code will include the drainage of any associated abscess cavity or infection. As with other areas of CPT, debridement of nonviable tissue associated with the breast implant or soft tissues is not reported separately. In other revised codes for 2021, the removal of the implant is an integral part of the procedure and not separately billable, such as in 19370 or 19371, where part of the
intracapsular contents is removed in a capsulectomy. (CPT Assistant April 2021, Vol. 31 Issue 4)

+15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk)

This add-on code corrects a soft tissue defect of the trunk or breast. It’s important to check individual payer coverage policies for approved products for this type of graft. Just because prior authorization for 15777 has been received or is not required, you are not guaranteed

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