AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 1; Ask the Editor

Nipple Reconstruction and Breast Reduction

The patient is a 38-year-old with a history of left breast malignancy (Her2-negative) status post modified left radical mastectomy, antineoplastic and radiation therapy. She has previously undergone reconstruction of the left breast by means of a deep inferior epigastric perforator (DIEP) flap. The patient is now admitted for left nipple reconstruction and to address the asymmetrical right breast. During surgery, a new nipple was created on the reconstructed left breast and the right breast was reduced to obtain symmetry relative to the left breast. What are the appropriate root operations for the creation of a new nipple on the reconstructed left breast and the reduction mammoplasty of the right breast? Is the reduction mammoplasty “Excision” or “Alteration”? ...

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