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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