Coding Atlas
Breast shapes may be surgically changed for cosmetic or therapeutic reasons. In mastopexy, a breast with ptosis is surgically lifted, with the nipple relocated to a higher position on the breast. In mammaplasty, fat, tissue, and skin may be removed to reduce the size of breasts or may be rearranged to enhance the appearance of the breast. In some mammaplasties, implants are inserted to increase breast size.
FIGURE 1- 9. Needle Core Biopsy
When a needle core biopsy of the breast is performed, a plug of tissue is drawn into a hollow needle that is inserted into a lesion. Multiple plugs may be taken from a single lesion. Needle core biopsies are reported once for each lesion sampled, regardless of the number of plugs sampled from each lesion. Note: Tools, implants, and/or equipment depicted in the illustration may be outdated but the procedural approach is valid.
Netter’s Atlas of Surgical Anatomy for CPT Coding
Integumentary System
19300—19307Moderate sedation :Add-on code Modifier 51 exempt #Resequenced code © 2015 American Medical Association 21
19361 Breast reconstruction with latissimus dorsi flap, without prosthetic implant
19364 Breast reconstruction with free flap 19366 Breast reconstruction with other technique
19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;
19368 with microvascular anastomosis (supercharging) 19369 Breast reconstruction with transverse rectus abdominis
myocutaneous flap (TRAM), double pedicle, including closure of donor site
19370 Open periprosthetic capsulotomy, breast 19371 Periprosthetic capsulectomy, breast 19380 Revision of reconstructed breast
19396 Preparation of moulage for custom breast implant 19316 Mastopexy
19318 Reduction mammaplasty
19324 Mammaplasty, augmentation; without prosthetic implant 19325 with prosthetic implant
19328 Removal of intact mammary implant 19330 Removal of mammary implant material
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 Delayed insertion of breast prosthesis following
mastopexy, mastectomy or in reconstruction 19350 Nipple/areola reconstruction
19355 Correction of inverted nipples
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
FIGURE 1-10. Nipple Reconstruction
Code 19350 is reported for many types of nipple reconstruction. Any cartilage harvest, flaps, grafts, or tattooing performed in the reconstruction of the nipple are considered inherent in code 19350.
Nipple reconstruction is often performed as part of the reconstruction postmastectomy.
Breast Reconstruction Breast reconstruction with tissue expander and implant
Pectoralis major muscle Tissue expander
Expander inflated to stretch tissue Tissue expander implanted;
after adequate expansion of tissue, replaced with standard implant
Tissue expander placed in subpectoral space
Skin flaps raised
Nipple mound completed and wounds closed Flap tucked in
to create nipple mound
Flaps rotated
Nipple-areola area usually tattooed 6 weeks postoperatively
Nipple
mound Reconstructed breast
Nipple-areola reconstruction
Tattooed areola
19316—19396
Integumentary System
Netter’s Atlas of Surgical Anatomy for CPT Coding22 Moderate sedation :Add-on code Modifier 51 exempt #Resequenced code
Nipple-areola reconstruction Pectoralis major muscle Tissue expander
Expander inflated to stretch tissue Tissue expander implanted;
after adequate expansion of tissue, replaced with standard implant.
Tissue expander placed in subpectoral space
Skin flaps raised
Nipple mound completed and wounds closed Flap tucked in
to create nipple mound
Flaps rotated
Nipple-areola area usually tattooed 6 weeks postoperatively
Nipple
mound Reconstructed breast
Nipple-areola reconstruction
Tattooed areola FIGURE 1-11. Tissue Expander
At the time of a mastectomy or during a later reconstruction, a tissue expander may be inserted under the skin and chest muscle. The expander is a balloon-like device that is expanded over time. The expander is attached to a portal through which fluid can be injected to increase the balloon’s size, allowing for gradual stretching of the overlying tissue. Note: Tools, implants, and/or equipment depicted in the illustration may be outdated but the procedural approach is valid.
Moderate sedation :Add-on code Modifier 51 exempt #Resequenced code © 2015 American Medical Association 23
Netter’s Atlas of Surgical Anatomy for CPT Coding
Integumentary System
FIGURE 1-12. Flaps in Breast Reconstruction
The transfer of tissue from other parts of the body to the breast area can help a patient achieve an acceptable cosmetic outcome following mastectomy. Sometimes, the flap remains attached at the donor site to maintain blood flow, ie, a transverse rectus abdominis myocutaneous flap (TRAM flap). Other times, a free flap of skin and subcutaneous tissue may be transplanted, with its blood vessels attached to vessels at the mastectomy site through microanastomosis.
Latissimus dorsi myocutaneous flap
Transposition rectus abdominis myocutaneous (TRAM) flap Myocutaneous flap passed anteriorly through skin tunnel
Muscular portion of flap
Cutaneous portion of flap
Saline implant or tissue expander implanted beneath flap Skin closed
over flap and implant
Latissimus dorsi myocutaneous flap raised Vascular supply intact
Pectoralis major muscle
Surgical defect after modified radical mastectomy
Flap passed into mastectomy defect via skin tunnel Myocutaneous flap based on vascular supply of rectus abdominis muscle raised contralateral to area of mastectomy
Abdominal wound closed Cutaneous
portion of flap Muscular portion of flap
Cutaneous portion of flap Breast mound formed from flap without implant
24 Moderate sedation :Add-on code Modifier 51 exempt #Resequenced code
Integumentary System
Netter’s Atlas of Surgical Anatomy for CPT Coding25
Axial skeleton (80) Skull (22) Cranium (8) Face (14) Associated bones (7) Auditory ossicles (6) Hyoid (1)
Sternum (1) Ribs (24)
Vertebrae (24) Sacrum (1) Coccyx (1)
Skull and associated bones (29)
Thoracic cage (25)
Vertebral column (26) Appendicular skeleton (134)
Clavicle (2) Scapula (2)
Humerus (2) Radius (2) Ulnar (2)
Femur (2) Patella (2) Tibia (2) Fibula (2) Tarsal bones (14) Metatarsal bones (10) Phalanges (28) Sesamoid (4) Pectoral
girdle (4)
Upper limbs (64)
Lower limbs (64) Pelvic girdle (2)
Carpal bones (16) Metacarpal
bones (10) Phalanges, (proximal, middle, distal) (28) Sesamoid (4) Coxal bone (hip bone) (2)
26