AHA Coding Clinic® for HCPCS - 2018 Quarter 4; Ask the Editor
Skin-sparing mastectomy
A patient underwent a right nipple-sparing mastectomy and a left skin-sparing mastectomy with a left axillary dissection. Should CPT code 19307 , Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle, be assigned when the surgeon does NOT state “modified radical mastectomy” but instead states “left skin sparing mastectomy and left axillary dissection?” Would it be appropriate to code these procedures separately? ...
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Article Overview
This article explains how a breast surgery operative report should be interpreted when terms such as skin-sparing and nipple-sparing mastectomy appear alongside axillary surgery. It is intended for coding professionals who need to assess procedure terminology, determine whether separate reporting is appropriate, and understand the general relationship between operative wording and CPT breast surgery coding.
Why This Topic Matters
Accurate interpretation of mastectomy documentation affects procedure selection, code assignment, and reporting consistency for breast surgery cases.
Article Sections
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Coding question
Introduces the operative scenario and the coding question being asked about breast surgery documentation.
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Technique overview
Describes the general skin-sparing mastectomy technique and its broad relationship to other mastectomy approaches.
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Coding guidance
Presents the article’s general coding direction based on the operative report and procedure wording.
What You Will Learn
- How the article frames skin-sparing and nipple-sparing mastectomy terminology
- What broad documentation issues are raised for breast surgery coding
- How the article discusses separate reporting of associated procedures at a high level
- How the article connects operative wording to CPT breast surgery coding considerations
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle staff
- Breast surgery documentation reviewers
Codes Discussed
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