Denial of Breast Reconstruction

Question:

We received a denial for 19357-50 (tissue expander reconstruction) and +15777 x 2 units. The denial reason was “the diagnosis code and CPT code combination is inappropriate”. We used a diagnosis of C50.911 (Malignant neoplasm of unspecified site of right female breast). What diagnosis code(s) should we have used?

Answer:

For breast reconstruction procedures, we typically use the following two diagnosis codes:

Z42.1 Encounter for breast reconstruction after mastectomyZ90.11 or Z90.12 or Z90.13 Acquired absence of right or left or bilateral breast

The cancer diagnosis code, such as C50.911, can be a third diagnosis if the mastectomy was performed on the same day as the reconstruction but we would not use it as a first diagnosis. Your procedure was performed for reconstruction – not to treat cancer. If the reconstruction were performed after the patient has completed all treatment for breast cancer, then you’d use Z85.3 (personal history of breast cancer) as a third diagnosis code.

*This response is based on the best information available as of 08/19/21.