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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Article Overview
This premium coding article addresses an operative scenario in post-mastectomy breast reconstruction and focuses on how to report the procedure in ICD-10-PCS. It is aimed at coders, coding educators, and revenue cycle staff who work with surgical coding for breast reconstruction and implant-related procedures. The article covers the relevant procedure concepts, root operation selection, and the identification of the appropriate ICD-10-PCS removal codes for the bilateral devices discussed in the case.
Why This Topic Matters
Breast reconstruction cases can involve multiple closely related procedure elements, and accurate ICD-10-PCS assignment depends on distinguishing the operative steps involved. This article helps readers understand the coding considerations for reconstructive breast surgery cases involving capsular work and device removal.
What You Will Learn
- How to approach a post-mastectomy breast reconstruction coding scenario
- How partial capsulectomy is considered in the context of ICD-10-PCS root operation selection
- How to identify the ICD-10-PCS procedure codes associated with bilateral tissue expander removal
- How reconstructive breast surgery cases may combine multiple operative components
Who Should Read This
- Inpatient coders
- Coding educators
- Clinical documentation improvement specialists
- Revenue cycle staff
- Health information management professionals
Codes Discussed
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