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AHA Coding Clinic® for HCPCS - 2026 Issue 2; Ask the Editor

Breast Implant Revision

A patient with a history of right breast cancer previously underwent right mastectomy with immediate implant-based reconstruction and subsequent left breast implant augmentation mastopexy for symmetry. The patient presented for revision due to excessive breast size.Attention was directed to the left breast. The nipple-areolar complex was marked for preservation, and a vertical mastopexy pattern was designed. De-epithelialization was performed.Dissection was carried through subcutaneous and glandular tissue to the level of the capsule. The existing left breast implant (140 cc) was identified and removed intact; no replacement implant was inserted.Following implant removal, the breast remained enlarged. Tissue excision was performed from the inferior medial, inferior, inferior lateral, lateral, and superior lateral portions of the breast. A total of approximately 125 grams of breast tissue was removed.Mastopexy was performed with elevation and rearrangement of breast tissue flaps, and repositioning of the nipple-areolar complex. The nipple-areolar complex remained viable throughout the procedure. Incisions were closed in layered fashion.What are the appropriate CPT codes for the left breast procedures? ...

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