icd 10 code for mastectomy and reconstruction

by Annalise Davis 6 min read

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.

Does insurance cover breast reconstruction after a mastectomy?

Under the WHCRA, group health plans, insurance companies, and HMOs that offer mastectomy coverage must also provide coverage for reconstructive surgery after mastectomy. This coverage includes reconstruction of the breast removed by mastectomy, reconstruction of the other breast to give a more balanced look, breast prostheses, and treatment of physical complications at all stages of the mastectomy, including lymphedema.

What to expect during and after mastectomy surgery?

  • Problems with the anesthesia
  • Bleeding
  • Blood clots
  • Fluid build-up in the breast or the donor site (for a tissue flap), with swelling and pain
  • Infection at the surgery site (s)
  • Wound healing problems
  • Extreme tiredness ( fatigue)

What do breast implants look like after a mastectomy?

Your individual results will depend on factors, such as:

  • Your natural breast tissue before and after mastectomy
  • Your unique body shape
  • Your lifestyle, which can affect the type of reconstruction that is best for you
  • Type of mastectomy performed
  • Choice of breast implants or natural tissue reconstruction
  • Reconstructive breast surgery technique

Is it possible to have breast implants after breast reduction?

After breast reduction surgery, most patients are satisfied with their results. Some women, however, opt to have breast augmentation years later to restore lost volume, primarily due to weight loss and postpartum changes, as opposed to breast augmentation after birth. It is common for breast shape and overall aesthetic changes to be made at the ...

What is the ICD-10 code for breast reconstruction following mastectomy?

1 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 double mastectomy?

Acquired absence of bilateral breasts and nipples The 2022 edition of ICD-10-CM Z90. 13 became effective on October 1, 2021.

What is the ICD-10 code for History of mastectomy?

Submit the appropriate ICD-10 diagnosis code that reflects a member's history of bilateral mastectomy, Z90. 13.

How do you code breast reconstruction?

Code 19380 [Revision of reconstructed breast] is a non-specific code intended to capture revisional procedures other than capsulotomies and capsulectomies. As the code descriptor states, in order to report 19380, the procedures must be performed on a breast that has already been reconstructed.

How do you code a bilateral mastectomy?

Report a “1” in the number-of-services field. For example, if you are billing for a bilateral mastectomy, you would report CPT code 19303 (Mastectomy, simple, complete) with the modifier. You would report the service as a single line item: 19303 50.

What is diagnosis code Z80 3?

Breast Cancer ICD-10 Code Reference SheetPERSONAL OR FAMILY HISTORY*Z85.3Personal history of malignant neoplasm of breastZ80.3Family history of malignant neoplasm of breast

What is the ICD-10 code for left mastectomy?

ICD-10 code Z90. 12 for Acquired absence of left breast and nipple is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What is the CPT code for mastectomy?

Report code 19303, Mastectomy, simple, complete, for the mastectomy.

What is the ICD-10 code for right prophylactic mastectomy?

Z40.01Z40. 01 - Encounter for prophylactic removal of breast | ICD-10-CM.

Can 11970 and 19370 be billed together?

The updated guidelines for 2021 instruct providers to use CPT code 11970 together with CPT code 19370 (Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy) in that scenario.

What is the difference between CPT code 19370 and 19371?

A CPT Assistant newsletter states “A capsulectomy (CPT code 19371) involves removal of the capsule. The implant is also removed and may or may not be replaced.” Therefore, CPT 19370 (capsulotomy) is included in 19328 when performed to remove the implant.

What is the CPT code for modified radical mastectomy?

The breast surgery Current Procedural Terminology (CPT) codes were developed when axillary dissection was standard therapy for breast cancer. Modified radical mastectomy is coded 19307; lumpectomy with axillary dissection is coded 19302.

What is the code for radical mastectomy?

The code for this type of more involved mastectomy is 19305 .

What is a complete mastectomy?

Radical mastectomy. For female patients, partial mastectomy involves excising the mass from the breast, taking along with it a margin of healthy tissue. The title of the procedure will be important when determining the physician’s intention for the procedure.

What is the Women's Health and Cancer Act?

The government passed the Women’s Health and Cancer Act (WHCRA) of 1998, enforcing coverage of reconstruction following mastectomies (if the plan allows for mastectomies). Check with your state’s Department of Insurance for your state’s coverage requirements.

What is subcutaneous mastectomy?

During a subcutaneous mastectomy (19304), the surgeon dissects the breast away from the pectoral fascia and skin. As with the simple complete mastectomy, the surgeon removes all of the breast tissue, but spares the skin and pectoral fascia. The documentation should clearly illustrate the more complex nature of this procedure.

What is a TRAM reconstruction?

TRAM reconstruction involves using the skin and muscles from the abdomen to create a breast. The advantage to this technique is that the tissue remains attached to its blood supply. For a single pedicle flap, report 19367. If the surgeon uses two pedicles of the rectus abdominis, report 19369.

What is the procedure to transfer skin from another part of the body to the breast area?

Three additional reconstruction procedures include transferring skin from another part of the patient’s body to the breast area. The latissimus dorsi flap (19361) describes a procedure during which muscle and skin are taken from the patient’s back and used to reconstruct a breast.

Can breast implants be done at the same time as mastectomy?

Breast implants are, perhaps, the most well-known reconstruction methods. These can be done during the same surgical session as the mastectomy (19340) or at a later time (19342). If reconstruction is delayed, the surgeon may perform a tissue expansion (19357).

General Information

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1833 (e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period..

Article Guidance

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38914, Cosmetic and Reconstructive Surgery. Please refer to the LCD for reasonable and necessary requirements.

ICD-10-CM Codes that Support Medical Necessity

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted. The following ICD-10-CM code supports medical necessity and provides coverage for (CPT) code: 15781 for Dermabrasion.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.