1. RECONSTRUCTIVE SURGICAL PROCEDURE CODING AND DOCUMENTATION OF BREAST
DIANA R. PHELPS, CPC, CPC-I, CEMC

2. OBJECTIVES Understand the anatomy of the breasts Check up and Tests
ICD-10-CM codes related to the breasts
Understand the coding of procedures
Define key terms
Review operative notes

3. ANATOMY

4. ANATOMY External anatomy consists of: Nipple Areola
Montgomery’s glands
Morgagni’s tubercles
Skin
Axillary tail
Inframammary fold
Margin of the pectoralis major muscle

5. ANATOMY (cont.) Internal anatomy consists of: Fascial layers
Retromammary space
Fibrous tissue/lobes
Lobules
Terminal ductal lobular unit
Adipose tissues
Cooper’s ligaments
Pectoralis muscle
Circulatory system
Lymphatic channels

7. REGULAR CHECK-UPS

8. TESTS
Mammograms
CAD
Digital
Ultrasound
Biopsies

10. ULTRASOUND OF BREAST

11. ICD-10-CM CHAPTER 2-NEOPLASM
Neoplasm table is after the Alphabetic Index to Diseases and Injuries. It is by body area and columns to choose from.
Distinguish the type of Neoplasm
Determine reason for the encounter
Treatment of malignancy then code malignancy as primary
Code radiation or chemotherapy as primary and neoplasm as second
When treatment/visit is aimed at the secondary site this is coded as the primary reason.
This is true even if the primary malignancy still exists.

12. ICD-10-CM CHAPTER 2-NEOPLASM (cont.)
Neoplasm continued
Patient returning after a recent surgery removing malignancy should code the malignancy as primary (even in the absence of finding further malignancy) until treatment is completed.
Patient with no signs of cancer after treatment use personal history code (V-code).
Treatment of complications for the malignancy or associated therapy are coded as primary and the malignancy is second.
Some neoplasm can be found under the term like melanoma

13. ICD-10-CM CHAPTER 2-NEOPLASM (cont.)
Majority of these codes will have a laterality character
Chapter 2 – Neoplasm (C44,5-, C50.-, C79.2, and D04.5, D05.-, D23.5, D48.5, D48.6-, D49.3)
Chapter 14- Disorder of the Breast (N60- N65)

14. ICD-10-CM CHAPTER 2-NEOPLASM (cont.)
C44.5 Other and unspecified malignant neoplasm of skin and trunk
C Unspecified malignant neoplasm of skin of breast
C Basal cell carcinoma of skin of breast
C Squamous cell carcinoma of skin of breast
C Other specified malignant neoplasm of skin of breast

15. ICD-10-CM CHAPTER 2-NEOPLASM (cont.)
C50- Malignant neoplasm of breast.
This category of codes is very specific as to the location and whether it is female or male

16. QUADRANTS OF THE BREAST
Tail of Spence

17. ICD-10-CM CHAPTER 2-NEOPLASM (cont.)
Samples of these codes
C Malignant neoplasm of central portion of right female breast
C Malignant neoplasm of lower-outer quadrant of left female breast
C Malignant neoplasm of lower-outer quadrant of right male breast
C Malignant neoplasm of overlapping sites of right female breast

18. OTHER NEOPLASM CODES C79.2 Secondary malignant neoplasm of skin
D04.5 Carcinoma in situ of skin of breast
D05.0- Carcinoma in situ of breast
D05.0- Lobular carcinoma in situ
D05.1- Intraductal carcinoma in situ
D05.8- Other specified type of carcinoma in situ
D05.9- Unspecified type of carcinoma in situ

19. OTHER NEOPLASM CODES (cont.)
D23.5 Other benign neoplasm of skin of breast
D48.5 Neoplasm of uncertain behavior of skin of breast
D48.6- Neoplasm of uncertain behavior of breast
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.3 Neoplasm of unspecified behavior of breast

20. DISORDERS OF THE BREAST
N60 Benign mammary dysplasia
N60.0- Solitary cysts of the breast
N60.1- Diffuse cystic mastopathy
N60.2- Firbroadenosis of breast
N60.3- Fibrosclerosis of breast
N60.4- Mammary duct ectasia
N60.8- Other benign dysplasias
N60.9- Unspecified benign dysplasia

21. DISORDERS OF THE BREAST (cont.)
N61 Inflammatory disorders of breast
N61.0 Mastitis without abscess
Cellulitis
N61.1 Abscess of the breast and nipple
Mastitis with abscess
Carbuncle of breast
N62 Hypertrophy of breast
Gynecomastia
N63 Unspecified lump in breast

22. DISORDERS OF THE BREAST (cont.)
N64 Other disorders of breast
N64.0 Fissure and fistula of breast
N64.1 Fat necrosis of breast
Code first breast necrosis due to breast graft- (T85.898)
N64.2 Atrophy of breast
N64.3 Galactorrhea not associated with childbirth
N64.4 Mastodynia

23. DISORDERS OF THE BREAST (cont.)
N64.5 Other signs and symptoms of breast
N Induration of breast
N Nipple discharge
N Retraction of nipple
N Other signs and symptoms in breast
N64.8 Other specified disorders of breast
N Ptosis of breast
N Hypoplasia of breast
Micromastia
N64.9 Disorder of breast, unspecified

24. DISORDERS OF THE BREAST (cont.)
N65 Deformity and disproportion of reconstructed breast
N65.0 Deformity of reconstructed breast
Contour irregularity
Excess tissue
Misshapen
N65.1 Disproportion of reconstructed breast
Breast asymmetry between native breast and reconstructed breast
Disproportion between native breast and reconstructed breast

25. BREAST BIOPSY
19081 Biopsy, breast, with placement of breast localization device(s) (eg. Clip,metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance
each additional lesion, including stereotactic guidance
Same except –including ultrasound
Same except- including magnetic resonance
19100 Biopsy of breast, percutaneous, needle core, not using imaging guidance (separate procedure)
19101 open, incisional

27. GUIDELINES FOR RECONSTRUCTION
Federal Guidelines and State Guidelines can be different so check your state.
Federal Guidelines permit reconstruction, mammoplasty and or mastectomy of bilateral breast to gain/achieve asymmetry
Lifetime coverage

28. INCISION
Most incisions are made below the breast or along the outer edge (axilla)
Generally mammoplasty incisions are made around the nipple or areola
Skin grafts may be necessary for complete closure. When TRAM flaps and other flaps are done-skin grafts may be necessary for closure of donor site. This is usually included.

29. MASTECTOMY
19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)
19302 with axillary lymphadenectomy
(For placement of radiotherapy alfterloading balloon/brachytherapy catheters, see )
19303 Mastectomy, simple, complete
(For immediate or delayed insertion of implant, see 19340, )
(For gynecomastia, use 19300)
19304 Mastectomy, subcutaneous

31. MASTECTOMY (19303)
Diagnosis: Breast cancer Operation performed: Bilateral total mastectomy and lymph node biopsy ( , LT) After induction of anesthesia, a curvilinear incision 1 cm below the hair bearing area of the left axilla was performed. Clavipectoral fascia was opened. Utilizing the gamma probe and blue dye, the sentinel lymph nodes were identified. The lymph nodes were both hot and blue. They were carefully dissected. Lymphatics and small blood vessels leading into the lymph nodes were cauterized and divided. The sentinel lymph nodes were sent to pathology for permanent analysis. Axillary incision was then irrigated and packed. Attention was then turned to the left breast. An elliptical incision was made encompassing the nipple areolar complex. Mastectomy skin flaps were created meticulously to preserve the subdermal blood supply and maintain a clear margin of resection around the tumor. The flaps were created superiorly just below the clavicle, medially up to the sternum, inferiorly up to the inframammary fold and laterally up to the mid axillary line. Dissection was carried down to the pectoralis fascia, which was included with the specimen. The specimen was submitted to pathology. The wound was irrigated. Adequate hemostasis was achieved and the wound packed. We proceeded in a similar fashion and simultaneously on the right breast.

32. MASTECTOMY Muscles and lymph nodes involved will determine code
19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes
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 pectoral minor muscle, but excluding pectoralis major muscle
All have the following statement below them:
(For immediate or delayed insertion of implant, see 19340, )

36. MAMMOPLASTY
19316 Mastopexy
19318 Reduction mammaplasty

37. MAMM0PLASTY (19318)
Diagnosis: Neck, bilateral shoulder and thoracic back pain, Macromastia (N62, M54.2, M25.511, M54.6) Operation Performed: Bilateral reduction mammoplasty ( ) Description: The patient was marked in the pre-operative area and then taken to the operating suite and placed on the operating table in the supine position. General endotracheal anesthesia was initiated. The arms were wrapped in Kerlix and the chest was prepped and draped in a normal sterile fashion. The breasts were infiltrated with a local solution, which consisted of 500 cc normal saline with 30 cc of 1 lidocaine with epi and an amp of epi 250 cc was injected into each breast, sparing the area of the pedicle. Attention was then first direct to the left breast. A tourniquet was placed using a lap sponge around the base of the left breast. Even tension was applied on the nipple-areolar complex and a 50 mm cookie cutter was used to mark the areolar incision. The pedicle was designed inferiorly with an 11 cm width. This was sharply incised and then the pedicle was de-epithelialized. Wise pattern marks were then sharply incised and taken down through dermis to the subcutaneous fat. The superior breast flaps were then developed. This was taken down to just above the pectoralis fascia. Breast tissue was then resected medially, taking care to prevent undermining of the pedicle. The dissection then continued above the pedicle to the lateral breast tissue, once again beveling outwards to prevent undermining of the pedicle. Additional tissue was removed from both the pedicle as well as thinning out some of the flaps as needed. Once this had been resected the tissue was weighed. The nipple was viable. The area was irrigated and hemostasis obtained and confirmed. A 2- 0 Vicryl was used to bring the T point of the incision together to check overall volume. The incision was closed temporarily with staples. Attention was then directed to the right breast and I proceeded in a similar fashion. The patient was sat up at this point to confirm the symmetry. The nipple positions were marked using a 45-mm cookie cutter. The patient was placed back in the supine position. The skin was de-epithelialized at the marked nipple locations incised in a cruciate pattern and the nipples were delivered through the opening. At this point, both incisions were closed in multiple layers using 3-0 Monocryl for the deep layer followed by 4-0 Monocryl for the skin. The patient tolerated the procedure well without complications.

38. PROSTHETIC IMPLANT PROCEDURES
19324 Mammaplasty, augmentation, without prosthetic implant
with prosthetic implant
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19396 Preparation of moulage for custom breast implant

39. IMPLANTS
Implants are placed in a pocket either directly behind the breast tissue or underneath the pectoral muscle which is located between the breast tissue and chest wall.

40. NIPPLE RECONSTRUCTION
19350 Nipple/areola reconstruction
It usually is done after the new breast has healed (3-4 months). Ideally they try to match the opposite side in color, size, shape and projection.
19355 Correction of inverted nipples

41. NIPPLE RECONSTRUCTION
Diagnosis: History of right breast cancer, status post bilateral mastectomies and status post bilateral breast reconstruction with a bilateral deep inferior epigastric perforators (DIEP) flap Operation performed: Bilateral nipple reconstruction with fishtail flaps ( ) Patient was seen and marked in the holding area for bilateral nipple reconstruction, and arrangements were made for her to come to the operating room. She was placed under general anesthetic with all of the appropriate monitoring, and the chest was prepped and draped in the usual standard fashion. The nipples had been marked, and once this was done, the fishtail flaps were elevated, the A and B wings were rotated on themselves and donor sites were closed. This was done simultaneously on both sides. At the end of the procedure, after all the wounds were closed, the nipples were covered with Dermabond and then allowed to dry, and then TopiFoam was applied over them to keep them from being compressed, and the patient was allowed to be awakened, extubated, and transported to the recovery room, where vital signs were stable.

42. NIPPLE RECONSTRUCTION
Before and After

43. REPAIR AND/OR RECONSTRUCTION
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19361 Breast reconstruction with latissimus dorsi flap, without prosthetic implant
(For insertion of prosthesis, use also 19340)
19364 Breast reconstruction with free flap
(Includes harvesting of the flap, microvascular transfer,
closure of the donor site, and inset shaping the flap into a breast )
(Do not report in addition to 19364)
19366 Breast reconstruction with other technique
(For insertion of prosthesis, use also or 19342)

44. BREAST RECONSTRUCTION (19357)
Diagnosis: Right breast cancer, upper outer quadrant, acquired absence of bilateral breasts (C50.411, Z90.13) Operation performed: Immediate bilateral breast reconstruction with placement of tissue expanders and ADM ( , ) Once the right mastectomy was completed. I was called into the room. Intraoperative fluorescent angiography was performed with the SPY. The perfusion to the skin flaps was evaluated and any tissue for resection was marked. I elevated the pectoralis muscle from lateral to medial direction, dividing the pectoralis origin to the sternal border. The wound was then irrigated with triple antibiotic solution and hemostasis was obtained using electrocautery. A medium contour, perforated, piece of thick Alloderm was prepared and rinsed in triple antibiotic solution. This was placed with the dermal side towards the skin flap and secured with a 2-0 Vicryl suture in interrupted fashion, beginning medially at the sternal border and progressing from medial to lateral along the inferior border of the pectoralis. It was then secured to the serratus fascia laterally. At this point, the pocket was irrigated once again with diluted betadine and then triple antibiotic solution. Good hemostasis was confirmed. A Mentor 535 cc ultra high artoura tissue expander was placed. The inferior border of the pectoralis was then secured to the superior border of the ADM using 2-0 Vicryl suture. The tissue expander was filled with 250 cc. This allowed good filling of the pocked without undue tension on the skin closure and good apposition of the ADM. A #15 round Blake JP drain was then placed and brought out through a separate lateral stab incision and secured with 3-0 nylon suture. The skin edges were freshened up. The incision was then closed in multiple layers using 3-0 Monocryl for the deep dermal layer followed by 4-0 Monocryl for the skin. Intraoperative fluorescent angiography was performed with the SPY. The perfusion to the skin flaps were elevated and if there was evidence of ischemic tissue to be resected, this was performed and the incision closed. We directed our attention to the contralateral side.

45. REPAIR AND/OR RECONSTRUCTION
19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;
with microvascular anastomosis (supercharging)
(Do not report in addition to 19368)
19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site

47. BREAST TATTOOING
The new option many are doing: