AHA Coding Clinic® for HCPCS - 2020 Quarter 3; Ask the Editor
Tissue expander replacement
A patient who is one month post delayed breast reconstruction, tripped and fell resulting in dehiscence of her right breast incision and exposure of her tissue expander. She presents for washout and replacement of the tissue expander. The dehisced skin edges were excised, previous sutures released, the tissue expander was removed from the pocket and the pocket was irrigated. The pocket had to be additionally dissected in order to accommodate the increased height of the replacement expander. All air was removed from the expander and it was placed into the pocket. What are the correct code (s) for the replacement of a tissue expander? ...
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Article Overview
This premium article explains a breast reconstruction coding scenario involving postoperative wound dehiscence and tissue expander replacement. It is intended for coders and billing staff working with breast surgery and plastic/reconstructive surgery cases, and it focuses on how the described procedure is handled within CPT when a more specific code is not available.
Why This Topic Matters
Accurate reporting of uncommon revision procedures can affect claim handling and documentation requirements. This article helps readers identify that the scenario falls into an unlisted-procedure pathway rather than a standard breast reconstruction code.
What You Will Learn
- How the described breast reconstruction complication is characterized for coding purposes.
- Why an unlisted CPT pathway may be relevant when no specific code fits the procedure.
- What type of documentation submission may be associated with an unlisted procedure report.
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Who Should Read This
- Medical coders
- Billing specialists
- Plastic surgery coders
- Breast reconstruction specialists
Codes Discussed
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