Coding & Billing: Inside Breast Reconstructions and Revisions
Your guide to getting reimbursed for breast surgery.
Denis Rodriguez, CPC, CCS
Breast surgery can be a challenge to code. Some payers, for example, won't cover reconstructive procedures on prior breast augmentations, while others will cover the reconstructive procedures, but not the implant replacement. Here's the latest on recent coding clarifications, as well as important details regarding implants and payer considerations.
Medicare Reimbursement for Breast Surgery
As the field of breast reconstruction and revisional surgery has evolved, so, too, have breast surgery CPT codes in both their purpose and intent.
|Procedure||CPT Code||ASC||OPPS||APC||Multiple Discount|
|Autologous fat transfer||19366||$1,379.81||$2,458.99||0029||Yes|
|Soft tissue reinforcement||15777||$623.76||$1,111.61||0136||Yes|
|Replacement of tissue expander with permanent prosthesis||11970||$1,928.93||$3,437.59||0051||Yes|
|Revision of reconstructed breast||19380||$1,815.79||$3,235.96||0030||Yes|
Autologous fat transfer
Although most breast reconstructions are performed with implants, some patients are opting for autologous fat transfer (AFT) procedures. In these procedures, the patient wears an external tissue expander such as the Brava device for about a month before the procedure. During the procedure, liposuction is performed to harvest fat for the breast reconstruction. The fat is centrifuged and placed into syringes, which are used to transfer the fat into the breast.
When AFT is the sole method of reconstructing the breast, report code 19366 [Breast reconstruction with other technique], according to the December 2011 CPT Assistant. The liposuction procedure to harvest the fat is not separately reported. Under both the ASC and OPPS payment systems, a multiple procedure reduction applies, which means the procedure on the contralateral breast is reduced for bilateral procedures performed on the same date of service.
There are a few things to consider with this procedure. Not long ago, placing fat grafts into the breast was not considered safe. Fat necrosis was common, and that complication could interfere with subsequent mammograms. With current techniques, including low suction pressure for the harvest of fat, centrifuging of the fat to remove fluids and injection of smaller fat particles into the breast, survival of the fat cells has improved significantly. However, this careful attention to the harvesting and processing of the fat increases operating times. Surgeries can average more than 1 hour and some can take up to 6 hours, increasing both the risk to the patient and the expense to the facility. Pay careful attention to patient selection criteria, and closely analyze the operating expenses for this procedure before adding it to your facility's offerings.
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