icd 10 code for bilateral breast reconstruction

The contralateral crescent mastopexy for symmetry is coded 19316 (or 19316-50 if bilateral). The ICD-10 codes for the lumpectomy are the location-specific C50 (malignant neoplasm of breast) code, and N65.1 (disproportion of reconstructed breast) for the mastopexy. Mark Gittleman M.D.

Full Answer

What is the purpose of a bilateral breast reduction?

Bilateral Breast Reduction (BBR) is a surgical procedure that reduces fat, glandular tissue and excess skin on large, heavy breasts. Bilateral breast reduction can help you achieve smaller, lighter breasts for a more shapely, attractive and comfortable breast contour.

What is a bilateral cyst in the breast?

When examined under a microscope, fibrocystic breast tissue includes distinct components such as:

• Fluid-filled round or oval sacs (cysts)
• A prominence of scar-like fibrous tissue (fibrosis)
• Overgrowth of cells (hyperplasia) lining the milk ducts or milk-producing tissues (lobules) of the breast
• Enlarged breast lobules (adenosis)

What is a bilateral mastectomy with reconstruction?

Mastectomy is the surgical removal of the breast, either a part or the whole breast. A double mastectomy, or bilateral mastectomy, removes both breasts. Following breast removal, a surgeon may perform breast reconstruction surgery. Learn more about mastectomy, including what to expect during recovery.

What is unilateral breast pain?

Noncyclic mastalgia is most common in women 40 to 50 years of age. It is often unilateral and is described as a sharp, burning pain that appears to be localized in the breast. Noncyclic mastalgia is occasionally secondary to the presence of a fibroadenoma or cyst, and the pain may be relieved by treatment of the underlying breast lesion.

What is the ICD 10 code for bilateral breast implants?

ICD-10-CM Code for Breast implant status Z98. 82.

What is the diagnosis code for bilateral mastectomy?

Acquired absence of bilateral breasts and nipples Z90. 13 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z90. 13 became effective on October 1, 2021.

What is bilateral breast mastectomy?

Double mastectomy When both breasts are removed, it is called a double (or bilateral) mastectomy. Double mastectomy is sometimes done as a risk-reducing (or preventive) surgery for women at very high risk for getting breast cancer, such as those with a BRCA gene mutation.

What is the difference between a simple and radical mastectomy?

A simple mastectomy (left) removes the breast tissue, nipple, areola and skin but not all the lymph nodes. A modified radical mastectomy (right) removes the entire breast — including the breast tissue, skin, areola and nipple — and most of the underarm (axillary) lymph nodes.

What is the ICD-10 code for breast reconstruction?

Z42.11 for Encounter for breast reconstruction following mastectomy is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What is the ICD-10 code for mastectomy?

Encounter for breast reconstruction following mastectomy Z42. 1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z42. 1 became effective on October 1, 2021.

What is the difference between a bilateral mastectomy and a double mastectomy?

A double mastectomy—also known as a bilateral mastectomy—is exactly what it sounds like: a surgery in which both breasts are removed at the same time. It's major surgery that removes both breasts to remove cancer, or to reduce the risk of breast cancer in a woman who may be at high risk for the disease.

What is bilateral mastectomy with reconstruction?

Mastectomy is the surgical removal of the breast, either a part or the whole breast. A double mastectomy, or bilateral mastectomy, removes both breasts. Following breast removal, a surgeon may perform breast reconstruction surgery. Learn more about mastectomy, including what to expect during recovery.

What is bilateral breast?

Bilateral breast cancer is when tumors develop in both breasts of the same patient. Compared to unilateral (one side) breast cancer cases, bilateral breast cancer patients tend to be younger and the tumors smaller and of an earlier stage at diagnosis. 1.

Can you have a mastectomy and reconstruction at the same time?

Breast reconstruction can be done at the same time as the mastectomy (“immediate”) or at a later date (“delayed”). Many women now get immediate breast reconstruction.

What is modified radical mastectomy vs radical mastectomy?

Both radical and modified radical mastectomy include removing the entire breast. During a modified radical mastectomy, the surgeon removes some underarm lymph nodes. The key difference is that in a radical mastectomy, the surgeon removes all the underarm lymph nodes plus the entire chest muscle.

What is the best reconstruction after mastectomy?

Breasts can be rebuilt using implants (saline or silicone). They can also be rebuilt using autologous tissue (that is, tissue from elsewhere in the body). Sometimes both implants and autologous tissue are used to rebuild the breast.

When will the ICD-10 Z42.1 be released?

The 2022 edition of ICD-10-CM Z42.1 became effective on October 1, 2021.

What is a Z40-Z53?

Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state. Type 2 Excludes.

When will the ICD-10 Z41.1 be released?

The 2022 edition of ICD-10-CM Z41.1 became effective on October 1, 2021.

What is a Z40-Z53?

Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state. Type 2 Excludes.

What is the correct CPT code for breast implant?

In this case, the physician removed the tissue expander and exchanged it for an implant in a straightforward fashion, without any extra work done to the breast or the capsule. CPT® 11970 is the correct code for this procedure.

What is the code for a bilateral tissue expander?

For example, the patient has bilateral tissue expanders with dermal matrix placed on May 1. This surgery is coded 19357-50 and 15777-50. The patient presents for her first fill on June 1, and has subsequent fills on June 17, June 30, and July 19. On Aug. 5 the patient returns again. This service is outside of the 90 day global period for the tissue expander insertion. During her visit for the fill, the physician completes a problem focused history and exam with straightforward medical decision-making. This visit is billed as 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making.

What is CPT code 11970?

CPT code 11970 alone does not account for this additional work, which is over and above removal of an expander and replacement with a permanent implant. The provider should document if the capsule was particularly thick or tight to support the extra effort involved for billing the higher service.

What is the code for a nipple tattoo?

Because nipple tattooing is calculated based on the total size of the areas, this is coded as 11921 and 11922. Because many payers reimburse breast reconstruction services only in relation to breast cancer, it’s prudent for providers to document current or past history of breast cancer in the operative report.

Why is code 19342 appropriate?

Code 19342 would be appropriate due to the extra amount of work involved with the surgery.

What is CPT 19357?

CPT® 19357 Breast reconstruction, immediate or delayed , with tissue expander, including subsequent expansion describes this first stage. The use of a dermal matrix, such as AlloDerm®, facilitates a higher initial expansion and is additionally billable with add-on code +15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code for primary procedure).

What is the procedure after a mastectomy?

Immediately after a patient’s mastectomy, a reconstructive surgeon will evaluate the skin flaps and prepare to insert a tissue expander. Following placement of the expander, the patient will present for subsequent fills of saline until the breast has expanded to the patient’s liking.