AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 2; Ask the Editor
Goldilocks Breast Reconstruction
The patient is a 62-year-old female with breast carcinoma and asymmetry, who presents for bilateral skin-sparing mastectomy with “Goldilocks” breast reconstruction. At surgery, the right breast was incised; long random-pattern flaps were raised and preserved. The breast was then elevated off the underlying pectoralis major muscle en bloc with the pectoralis major muscle fascia. Attention was then directed to the left side where an identical procedure was performed. Following mastectomy, plastic surgery examined the mastectomy flaps and proceeded with the “Goldilocks” procedure. De-epithelialization of the inferior pole skin was done. This was folded onto itself and sutured in place in the standard fashion. This was performed bilaterally. The skin incisions were brought together in layers. What is the correct root operation for a “Goldilocks” breast reconstruction? ...
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Article Overview
This premium article explains a breast reconstruction coding scenario centered on a bilateral mastectomy case and a specific reconstructive technique. It is intended for coders who need to understand the procedural context, reconstructive approach, and ICD-10-PCS root operation selection considerations discussed in the article.
Why This Topic Matters
Procedural coding for breast surgery can depend on how reconstruction is performed and how the operative steps are classified in ICD-10-PCS. This article helps readers evaluate the surgical context and the coding framework involved without relying on guesswork.
What You Will Learn
- How the article frames a breast reconstruction case in the context of ICD-10-PCS
- What procedural concepts are relevant to reconstructive coding in this scenario
- How the article approaches selection of the appropriate root operation at a high level
- How the surgical context of mastectomy and reconstruction affects code assignment analysis
Who Should Read This
- ICD-10-PCS coders
- Inpatient coders
- Coding educators
- Medical coding auditors
- Breach/billing compliance reviewers
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