AHA Coding Clinic® for HCPCS - 2021 Issue 2; Ask the Editor

Tissue expander exchange

A patient presented seven weeks status post first stage bilateral pre-pectoral breast expander-implant reconstruction. Fluid collection had developed along the incision on the right breast with thinning of the skin so that the expander could be visualized, requiring treatment to prevent implant exposure and infection. The skin was incised, implant pocket was entered and the expander removed. Acellular dermal matrix, was removed from the breast skin and subcutaneous fat and the implant pocket was debrided. A new expander was placed in the pocket with replacement of acellular dermal matrix. Is CPT code 19371 or 19357 the correct code to capture debridement of the implant pocket with removal and replacement of tissue expanders with dermal graft? ...

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