AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 1; Ask the Editor

Maxillectomy with Reconstruction of Maxilla

A patient with mucosal melanoma involving the left maxillary alveolus and sinus is admitted for left maxillectomy with obturator reconstruction. The surgeon proceeded with an inferior and anterior wall maxillectomy including resection of the medial maxilla and pterygoid wedge, down below the level of the infraorbital foramen. Once it was felt that wide surgical margins were achieved, a prefabricated obturator was placed, completely filling the maxillary defect. In this case, the primary objective of the maxillectomy is to remove cancerous tissue, which is a distinct objective from the reconstruction. Can the rationale for mastectomy with reconstruction published in Coding Clinic, Third Quarter 2018, page 13, be applied in this case with separate codes assigned for the maxillectomy and obturator placement? ...

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