AHA Coding Clinic® for HCPCS - 2018 Issue 4; Ask the Editor

Skin-sparing mastectomy

A patient underwent a right nipple-sparing mastectomy and a left skin-sparing mastectomy with a left axillary dissection. Should CPT code 19307, Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle, be assigned when the surgeon does NOT state “modified radical mastectomy” but instead states “left skin sparing mastectomy and left axillary dissection?” Would it be appropriate to code these procedures separately? ...

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