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AHA Coding Clinic® for HCPCS - 2026 Issue 1; Ask the Editor

Mastectomy with Pectoralis Major Muscle Excision

A patient with left breast carcinoma presented for a left total mastectomy. An elliptical incision was made circumferentially around the nipple-areolar complex. Skin flaps were developed superiorly, inferiorly, medially, and laterally extending to the clavicle, sternum, inframammary fold, and latissimus dorsi muscle. The breast tissue was dissected free from the pectoralis major muscle and excised in its entirety. The specimen was oriented to the axillary tail and submitted for pathologic evaluation.Following breast removal, inspection and palpation of the lateral aspect of the pectoralis major muscle revealed multiple nodular areas suspicious for metastatic disease. A partial resection of the pectoralis major muscle was performed at the 2 o’clock position on the chest wall, extending down to the pectoralis minor muscle and submitted as a new surgical margin. This specimen was designated as a new surgical margin and submitted for permanent section.Attention was then directed to the left axilla. Using a gamma probe and Scout localization, axillary tissue containing multiple lymph nodes was excised. Specimen radiography confirmed the clip and Scout within the specimen, which was submitted for frozen section. Further gamma probe interrogation demonstrated additional uptake near the chest wall. Additional axillary tissue was excised and submitted for permanent section. Reinspection of the chest wall revealed persistent nodularity involving the pectoralis major muscle, and additional portions of the pectoralis major were resected.Which CPT procedure code captures the mastectomy procedure with pectoralis major muscle excision? ...

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