AHA Coding Clinic® for HCPCS - 2017 Issue 3; Ask the Editor

Chest reconstruction after bilateral mastectomies

A patient with history of breast cancer and bilateral mastectomies opted out of reconstruction and is now being seen at our facility for chest reconstruction due to contour issues of her chest with indented painful scars and redundant skin at the mastectomy sites. The areas of redundant skin and scar tissue measure 22 cm x 4 cm on the right and 20 cm x 5 cm on the left. These were excised down to the subcutaneous fat overlying the pectoralis major muscle. Skin flaps were elevated from the upper abdomen allowing for advancement on the right and left chest and the skin was closed via staples.  The fat from the abdomen and flanks was harvested and placed in syringes for the administration of fat to the areas of defect. Once the fat was administered, the incisions were closed. The previous mastectomy scars were treated. The right chest scar was injected with 0.4 cc of Kenalog and the left chest scar was excised (full thickness) and also injected with Kenalog. All incisions were closed. Our facility wants to report CPT codes 13100 and 13102 x 7 due to the scar revision, 19366 for the fat grafting, 11900 for the Kenalog injections. Are these the correct codes? ...

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