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

Reduction Mammoplasty for Breast Symmetry

A 44-year-old presents with a palpable mass in the upper quadrant of the left breast. The patient underwent wide excision of the left breast mass, diagnostic left axillary lymphadenectomy, therapeutic reduction mammoplasty of the left breast and reduction mammoplasty on the right breast for symmetry. Based on documentation in the operative report of “left therapeutic reduction mammoplasty,” would the root operation “Excision” be appropriate for the therapeutic mammoplasty on the left since it was performed to excise the left breast mass? Would the root operation “Alteration” be assigned for the right mammoplasty performed to obtain symmetrical breasts? ...

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