AHA Coding Clinic® for HCPCS - 2023 Issue 1; Ask the Editor
Excision of positive margin following mastectomy
A patient presents to surgery one week post complete mastectomy, for re-excision of positive muscle margins. The patient was thought to have residual tumor invading the skeletal muscle involving the posterior margin. The mastectomy incision was opened and the area of muscle where the previous mastectomy specimen was taken was identified. A 7 cm x 3 cm piece of full-thickness pectoralis muscle all the way through to the capsule down to the expander was excised. Due to additional visible sutures in the wound, an additional 5 cm x 3 cm contiguous section of full-thickness pectoralis muscle was excised to the midline. Pathology confirmed the specimens were clear. The muscle defect was closed in a buried fashion, antibiotic beads were placed beneath the skin and then the skin was closed with sutures in a buried and subcuticular fashion. Is a CPT code from the musculoskeletal section more appropriate such as 21554, Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5cm or greater or, 21558, Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax, 5cm or greater, for the muscle and capsule excision? How is the re-excision of the positive muscle margin following complete mastectomy reported in this case? ...
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