AHA Coding Clinic® for HCPCS - 2023 Quarter 1; Ask the Editor
Excision of redundant tissue post-mastectomy
A patient underwent bilateral mastectomies without reconstruction. She now presents for bilateral excision of redundant and excessive skin. She also had bilateral seromas, which contributed to the formation of the excess tissue. The right breast skin and soft tissue were anesthetized. An elliptical incision was made and the redundant tissue was excised. The dissection was carried down to the anterior chest wall. The excised area measured 6 cm. The redundant area of the right axillary region was excised and the wound measured 18 cm. The deep tissue wounds at both sites were closed in layers. The skin and soft tissue of the left mastectomy site was anesthetized. She developed a painful cicatrix medially. An elliptical incision was made and the 6 cm cicatrix was excised. Only medial breast tissue required excision. Her breast tissue remaining on the left was without diagnostic abnormality. The deep tissue wound was closed in layers. All three deep wounds were closed and dressed. How is the excision of redundant skin status-post mastectomy coded for a patient who has not undergone prior breast reconstruction? ...
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Article Overview
This premium article reviews a post-mastectomy excision scenario involving redundant skin and soft tissue after bilateral mastectomies without reconstruction. It is aimed at surgeons, coders, and billing professionals who need to understand how the operative details, anatomical sites, and wound measurements are presented in the context of CPT surgical coding. The discussion focuses on the procedure narrative, site-specific operative findings, and the documentation elements that influence code interpretation.
Why This Topic Matters
Post-mastectomy revision procedures can be documented in ways that overlap several surgical categories, making accurate understanding of the operative note important for coding, claims review, and record interpretation.
What You Will Learn
- How the operative note describes excision of redundant tissue after mastectomy
- How multiple anatomic sites and wound measurements are documented in the procedure
- What documentation elements are relevant when reviewing a post-mastectomy revision operative report
- How surgical closure details are presented in the context of the case
Who Should Read This
- Coders
- Coding auditors
- Surgeons
- Billing staff
- Revenue cycle professionals
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