AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 3; Ask the Editor

Bilateral Breast Capsulectomy and Tissue Expander Removal

A patient with a history of left breast cancer status post bilateral mastectomy and tissue expander placement presents for reconstructive surgery and removal of tissue expanders. The patient was found to have anterior capsule contractures on both sides. A greater degree of capsular contracture was found on the left side with elevation of tissue expander and breast contour on this side. Prior to reconstructive surgery, bilateral partial capsulectomies were performed by excising and removing the anterior capsules along with the tissue expanders. What is the appropriate root operation for the partial capsulectomy? What are the appropriate ICD-10-PCS codes for the removal of bilateral tissue expanders? ...

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