Number of Units for ADM Code (+15777)

Question:

I use two ADMs on each breast during a tissue expander reconstruction. Can I bill +15777 x 4 units?

Answer:

No, you’ll use the code +15777 once for each breast

Question:

I’m confused on whether to bill +15777 twice (once on each side) or with modifier 50. Please advise.

Answer:

Good question and we completely understand the confusion. CPT says not to use modifier 50 – rather, you’ll report +15777 x 2 units for bilateral procedures. However, Medicare’s Medically Unlikely Edits allow only 1 unit of +15777 to be paid per day. Therefore, for Medicare (and payors who follow Medicare guidelines), you’ll report +15777 with modifier 50 for bilateral procedures.

*This response is based on the best information available as of 04/01/21.

Oncoplastic Reconstruction

Question:

I just realized CPT 19366 was deleted in 2021. Now what code do I use for an oncoplastic reconstruction?

Answer:

You’re right – CPT 19366 (Breast reconstruction with other technique) was deleted this year. You will code for whatever procedure you end up doing such as an adjacent tissue transfer (e.g., 14xxx), breast reduction (19318), or mastopexy (19316).

*This response is based on the best information available as of 03/18/21.

Coding 23395 for Pectoralis Muscle Repair

Question:

Someone told us to bill 23395 for repairing the pectoralis muscle after removing breast implants. Here’s the common scenario:

• Removal of old bilateral breast implants with capsulectomies
• Repair of pectoralis muscle with re-attachment to chest wall
• Creation of pre-pectoral pocket with acellular dermal matrix
• Placement of bilateral breast implants for reconstruction

What do you think of the recommendation to code 23395?

Answer:

Let’s look at the details. The CPT descriptor for 23395 says “Muscle transfer, any type, shoulder or upper arm; single”. First, are you doing a muscle transfer? No – your scenario says “re-attachment to chest wall” which is not a transfer. Second, are you operating on the shoulder or upper arm? No – your scenario says “breast” and “pectoralis muscle” and “chest wall” which is neither the shoulder or upper arm. Lastly, does your patient scenario look like the typical patient scenario described by CPT? “This is a 35-year-old patient with scapular disability and pain caused by scapular winging undergoes pectoralis major transfer.” No.

Your scenario says “repair” so we ask how the muscle got to a point where it needed to be repaired. The usual scenario is that the surgeon partially detached the muscle to place the implant. Therefore, we do not agree that “repair” of the pectoralis muscle by re-attaching to the chest wall, or putting the muscle back to its original place, would be separately reported. We believe this service is included in whatever code(s) you choose for the breast reconstruction procedure and separately reporting 23395 is not accurate. If there is additional significant work, then you could potentially append modifier 22 to your primary procedure code.

Stay tuned for major CPT code changes to the breast reconstruction codes starting 1/1/21….Kim Pollock will have an upcoming webinar about the changes.

*This response is based on the best information available as of 12/03/20.

Tissue Expander Exchange with Breast Reconstruction Revision

Question:

At the time of the second stage tissue expander exchange, my plastic surgeon wants to bill 19380 for either liposuction, removing excess scar tissue, removing redundant excess skin or removing adipose tissue. “The lateral aspect of the mastectomy scar is excised along with redundant skin and subcutaneous tissue to revise the reconstructed right breast.” Can 11970 and 19380 be billed together?

Answer:

CPT states that 19380 may be reported for breast revision after reconstruction has taken place. At the time of a 2nd stage, expander to implant procedure, the reconstruction is just now being finalized. Therefore, 19380 would not be reported with 11970 for the same breast. If the expander to implant procedure is more extensive, due to the reasons you list, then you could potentially report 19342 instead of 11970.

*This response is based on the best information available as of 09/03/20.

Carotid Artery Exploration with Free Flap to Oral Cavity

Question:

Can we report 35701 for the carotid vessel exploration in the recipient site when doing a fibula free flap (20969)?

Answer:

No, this activity is included in the free flap code. CPT specifically states not to 35701 to explore and identify a recipient artery [eg, external carotid artery] when performed in conjunction with free flap codes including 15756, 15757, 15758 and 20969.

*This response is based on the best information available as of 07/23/20.

Complex Closure of Free Flap Donor Site

Question:

I did a right anterolateral thigh free flap and had to close the right thigh wound (4 x 8 cm) with undermining of additional 3 cm in either direction to close the wound without any significant tension. Can I also code a complex repair (13100, +13101) with the free flap code?

Answer:

Bringing the wound edges directly is included in the free flap code. However, CPT says that repair of donor site requiring skin graft or local flaps (e.g., adjacent tissue transfer requiring a separate skin incision to create a secondary defect) may be separately reported. Additionally, Medicare has a National Correct Coding Initiate (NCCI) edit between the free flap codes and the complex repair codes which could not be overridden because the procedures are in the same area. So, no, a complex repair code would not be used for closure of the flap donor site.

*This response is based on the best information available as of 07/09/20.