AHA Coding Clinic® for HCPCS - 2016 Issue 3; ASK THE EDITOR
Removal of breast implant
A patient underwent a right periprosthetic capsulectomy of the breast two weeks ago. At the one-week period she was perfectly symmetrical. The patient noticed that her right breast was slowly enlarging and becoming painful. There was no way to tap the pocket with a needle without damaging the silicone implant, therefore, removal of the implant with drainage of the pocket and replacement of the original implant was performed. According to the operative report the original breast implant was reinserted following the drainage of fluid from the breast. Can CPT code 19340 be coded as well as CPT code 19328 when breast implant was removed solely to gain access to a post-operative hematoma/seroma? ...
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Article Overview
This premium article addresses a breast surgery coding scenario involving postoperative swelling and drainage after a prior capsulectomy. It is aimed at coders and billing professionals who need to understand how the operative note, procedure intent, and postoperative complication context affect CPT code selection. The article also points to related incision-and-drainage coding considerations for soft tissue hematoma or abscess.
Why This Topic Matters
Procedural documentation in breast implant cases can change how services are reported, especially when a procedure is performed to access or manage a postoperative collection. Understanding the coding implications helps support accurate claim submission and consistent interpretation of operative reports.
What You Will Learn
- How breast implant removal scenarios are evaluated for CPT reporting
- How postoperative hematoma or seroma context affects coding review
- How operative documentation is interpreted in relation to implant reinsertion
- How related incision and drainage coding topics may be considered in soft tissue cases
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Revenue cycle professionals
- Breast surgery practices
Codes Discussed
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