Coding, Classification & Reimbursement

CPT breast reconstruction - fat grafting

  • 1.  CPT breast reconstruction - fat grafting

    Posted 13 days ago
    Edited by Veronique Van Hoof 13 days ago
    our coder's have different views on this procedure and would like some insight - personally I would code the below as 19366-50, 15877 (facility out patient hospital)

    and insight on this would be greatly appreciated- surgeon believes it should be a unlisted breast procedure. I believe 19366 fits better

    OSTOPERATIVE DIAGNOSES:

    1. History of breast cancer.

    2. Status post bilateral mastectomy and reconstruction with deep inferior epigastric perforator flaps.

    3. Asymmetry of the breasts.

    4. Contour deformity of the upper breasts with the left side being smaller.

     

    OPERATIONS PERFORMED:

    1. Revision of reconstructed right and the left breast by removal of the skin paddle and performing local tissue rearrangement in the form of mastopexy.

    2. Correction of the contour deformity and the volume asymmetry of the right and the left breast by fat grafting.

    3. Harvesting of the fat from the upper abdomen, lower abdomen, and flanks and hips.

     

     

    INDICATIONS FOR THE OPERATION:  This is a patient who basically has had previous operation for breast cancer.  She has mastectomy and reconstruction with a DIEP flap.  She has now asymmetry of the breasts with the breasts being more ptotic.  The skin island was much below the nipple-areolar complex area.  It appeared to be on measurements that she has lost some weight and suffers from ptotic breasts, and she has contour deformity of the upper breasts with volume asymmetry with the left side being smaller.

     

     

    DESCRIPTION OF PROCEDURE:  With that in mind, she was marked in the preoperative holding area; the Wise pattern and then after that the area where the fat to be harvested, and then the patient was taken to the operating room and placed in the supine position.  Anesthesia was induced.  The area was prepped and draped in the usual sterile fashion.  Starting with the tumescent solution, multiple stab incisions at the previous incision inferiorly were made, and then tumescent solution was injected in the right and left flanks, upper abdomen, and lower abdomen.  The total amount that was injected was almost 1800 mL.  Then, while waiting for the vasoconstriction effect, using the Wise pattern, breast revision in the form of mastopexy with a local tissue rearrangement was done.  The skin was deepithelialized.  The skin pedicle was removed and then elevated superiorly.  The mastectomy flaps on either side were advanced and closed in basically an inverted-T incision.  The same was done on the left side.  The patient was placed in the upright position, and looked very good after doing the local tissue rearrangement and the excision of the skin paddle on both sides.  There was definitely a contour deformity medially and superiorly on the left and also on the right and volume difference.  So, with that in mind, we elected to harvest the fat.  First, pretunneling was done.  The fat was harvested with the size 3 cannula under low machine suction.  Multiple pretunneling was done passing in both flanks.  The amount of the fat that was harvested from the flanks was in symmetrical fashion, upper abdomen and the lower abdomen.  The fat that was harvested, total aspirate was about 2 liters.  That was taken to be washed.  It was in a closed suction system called red ball.  Then after that, using a small cannula, 2.5 mm, feathering to smoothen the area of the upper abdomen, lower abdomen, and the flanks was done, and total amount that was suctioned with the feathering was about 2000 mL.  Meanwhile, after the fat was purified and washed, it was injected in multiple planes ismall quantity about 5 to 10 mL used with a small cannula.  It was mainly to correct the contour deformity, so most of the injection was deep dermal and subcutaneous tissue.  There was no intramuscular injection.  Then, the same was done on the left side.  The total amount that was injected on the right was 200 mL and on the left was 320 mL because of the volume difference.  The patient was placed in the upright position to look for the symmetry that was improved.  Then after that, the incisions were closed with interrupted 5-0 Prolene.  Compression garment was placed onto the abdomen.  On the breasts, a non-pressure dressing was applied.  The patient was transferred to the recovery room with stable vital signs and in stable condition.

     



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    Veronique Van Hoof
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  • 2.  RE: CPT breast reconstruction - fat grafting

    Posted 12 days ago

    I would code this with CPT 19380 - Revision of reconstructed breast.  This code includes repositioning the breast; making adjustments to the inframammary crease; making capsular adjustments; and performing scar revisions, fat grafting, liposuction, and so on.

    See CPT® Assistant December 2017 / Volume 27 Issue 12



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    Joyce Mauney
    Coding Facilitator
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  • 3.  RE: CPT breast reconstruction - fat grafting

    Posted 12 days ago

    Hi Veronique.  Since this was a revision of reconstructed breasts, I would use cpt code 19380 with modifier 50, and for the fat grafts, I would use 20926.


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    Cheryl Anderson, CCS, CCS-P
    Coding Auditor
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  • 4.  RE: CPT breast reconstruction - fat grafting

    Posted 11 days ago
    Thank you for you input the reason I chose 19366 is base of cpt assistant december 11, page 14. As this is post matectomy which is the main reason for revision.

    CPT Assistant.
    Surgery: Integumentary System

    Question 2:

    One of our plastic surgeons performs liposuction on postmastectomy breast cancer patients and then injects the autologous fat into the breast as a method of reconstructing the breast. Is CPT code 19366, Breast reconstruction with other technique, appropriate to use in this case? Michele A. Wrightson, CCS-P

    Answer 2:

    Yes. Code 19366 is the appropriate code for this extensive procedure when the sole method of reconstructing the breast postmastectomy is with fat injection. The harvest of the fat is not reported separately. However, i the reconstructed breast requires a revision, the code to be reported would depend on the extent of the revision.


    Any more thoughts or comments on this would be great. As our surgeon will be doing many of these.

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    Veronique Van Hoof
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  • 5.  RE: CPT breast reconstruction - fat grafting

    Posted 11 days ago
    I would code everything to just one code, 19380-50.  This is a comprehensive code as it covers multiple distinct breast reconstruction-related procedures and as explained in CPT Asst. The patient has already had a major breast reconstruction which is the DIEP (ie, autologous reconstruction and not involving implants) and now comes back in to correct the breast disproportion.  Code 19366, as CPT Asst explains, is a type of major reconstruction that involves fat graft only;  the fat used is to create the new  breast(s) and not as a supplemennt.  Your scenario descibes filling in the deformity or asymmetry, which may be reported with a code from 2xxxx, as the previous poster mentioned in situations where it can be distinctly reported. Code 19380 already includes fat grafting, so reporting the 2xxxx fat graft code would not be necessary in this case.

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    Cristina Co
    Facility Outpatient Coder
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  • 6.  RE: CPT breast reconstruction - fat grafting

    Posted 10 days ago
    Cpt code 19380-50 can be coded with 20926.  Fat grafts are not included in cpt code 19380.  However, cpt code 20926 had an APC  value of "N'", meaning it is packaged in with the primary procedure's APC.


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    Cheryl Anderson, CCS, CCS-P
    Coding Auditor
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  • 7.  RE: CPT breast reconstruction - fat grafting

    Posted 8 days ago
    ​Hi All,

    This is an area that has been discussed much at my facility as the info in CPT Assistant and CC for HCPCS has seemed in contradiction at times.

    Based on the info form December 2017 we are telling our coders to only code 19380 - see info below:

    Revision of reconstructed breast, correct reporting

          CPT Assistant, December 2017 Page: 13 Category: Frequently Asked Questions

          Related Information

     

    Surgery: Integumentary System

     

    Question:

     

    Does the procedure described by code 19380 include making a separate incision from the previous breast construction area to achieve symmetry if the elliptical incision measures 10 cm on the lateral chest, for example, not inclusive of the mammary fold?

     

    Answer:

     

    CPT code 19380, Revision of reconstructed breast, is a global service that includes all maneuvers involved in revising an already reconstructed breast, even when multiple maneuvers are performed. This includes repositioning the breast; making adjustments to the inframammary crease; making capsular adjustments; and performing scar revisions, fat grafting, liposuction, and so on. Therefore, it is not appropriate to report additional codes.

     




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    Lisa Withers
    Coding QI Compliance Auditor and Trainer
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  • 8.  RE: CPT breast reconstruction - fat grafting

    Posted yesterday
    Thank you everyone for your input. This has helped a lot.

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    Veronique Van Hoof
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