Breast Repair and/or Reconstruction: Changes for 2021
CPT Assistant, April 2021, Volume 31, Issue 4, page 3
For the Current Procedural Terminology (CPT®) 2021 code set, a significant number of codes were revised or deleted in the Breast subsection of the Integumentary System section. In addition, new introductory guidelines were added to the Repair and/or Reconstruction subsection, along with numerous instructional parenthetical notes. All of these changes were made to reflect current practice, simplify terms, and clarify physician work. This article provides an overview of these changes.
Introduction
(Do not report 11971 in conjunction with 11960, 11970)
(For removal of breast-tissue expander and replacement with breast implant, use 11970)Codes 11970 and 11971 were revised to replace the term "prosthesis" with "implant" for simplification and clarification. The term "breast implant" is intended to reflect saline- or silicone gel-filled implants. Note that clips, markers, or other materials are not considered breast implants for coding purposes. In addition to the revised descriptors, two new parenthetical notes were added to synchronize with the revised codes and new guidelines in the Repair and/or Reconstruction subsection.
Repair and/or Reconstruction
(19324 has been deleted. To report breast augmentation with fat grafting, see 15771, 15772)(For fat grafting performed in conjunction with 19325, see 15771, 15772)(Do not report 19328 for removal of tissue expander)(Do not report 19328 in conjunction with 19370)(For removal of tissue expander with placement of breast implant, use 11970)(For removal of tissue expander without replacement, use 11971)(Do not report 19330 for removal of ruptured tissue expander)(For removal of ruptured tissue expander with placement of breast implant, use 11970)(For removal of ruptured tissue expander without replacement, use 11971)(For placement of new breast implant during same operative session, use 19342)(Do not report 19342 in conjunction with 19328 for removal of implant in same breast)(For removal of tissue expander and replacement with breast implant, use 11970)(For insertion of breast implant with latissimus dorsi flap on same day of mastectomy, use 19340)(For insertion of breast implant with latissimus dorsi flap on day separate from mastectomy, use 19342)(For insertion of tissue expander with latissimus dorsi flap, use 19357)(19366 has been deleted)(19361, 19364, 19367, 19368, 19369 include harvesting of the flap, closure of the donor site, insetting and shaping the flap)(Do not report 19370 in conjunction with 19328 for removal and replacement of same implant to access capsule)(For removal and replacement with new implant, use 19342)(Do not report 19371 in conjunction with 19328, 19330)(Do not report 19371 in conjunction with 19370 in same breast)(For removal and replacement with new implant, use 19342)(Do not report 19380 in conjunction with 12031, 12032, 12034, 12035, 12036, 12037, 13100, 13101, 13102, 15877, 19316, 19318, 19370, for the same breast)New Introductory Guidelines
New introductory guidelines were created for breast repair and/or reconstruction to clarify the different reconstructive techniques and provide users with coding guidance for surgeries that are designed to correct anatomic defects and to restore form and breast symmetry. According to the new guidelines:
Breast reconstruction is performed to repair defects due to congenital anomaly or loss of breast tissue after a surgical excision. The goal of breast reconstruction is to correct the anatomic defect and to restore form and breast symmetry. A breast can be reconstructed using a single technique or a combination of techniques, and each technique can stand alone. In addition, both breasts may be reconstructed at the same time, but may use different techniques or a combination of techniques. In many instances breast reconstruction requires more than one planned procedure or may require revisions.
Understanding the Revised Codes
The following is an overview of revised codes 19318, 19325, 19328, 19330, 19340, 19342, 19357, 19361, 19364, 19367-19371, and 19380, which may include additional guidance on other codes that are related or pertinent to the described procedure(s), as applicable.
Code 19318 was revised by replacing "reduction mammaplasty" with "breast reduction." Similarly, the descriptor for code 19325 was revised from "mammaplasty, augmentation; with prosthetic implant" to "breast augmentation with implant." In addition, code 19325 was converted from a child code to a parent code. A parenthetical note also was added after code 19325 to direct code users to report codes 15771, Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate, and 15772, each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure), when fat grafting obtained by liposuction is performed, either in conjunction with a breast augmentation with implant or if used as an independent technique for breast augmentation.
Code 19328 is used to report the removal of an intact breast implant and includes the drainage of any associated abscess cavity or infection. In addition, debridement of nonviable tissue associated with the breast implant or soft tissues is not reported separately. Code 19328 may not be reported when a new breast implant is being placed (19340, 19342) because the work of removal is included in the work of placing the new implant. Code 19328 is not reported with code 19370 (capsule revision) because implant removal is inherent to the procedure of revising the capsule. Finally, code 19328 is not reported with code 19371 (complete capsulectomy) because intact breast implant removal (19328) includes part of the intracapsular contents, which is removed in a complete capsulectomy.
Code 19330 was revised to include the removal of both the implant and its contents, such as saline or silicone gel, for a ruptured breast implant. Code 19330 may not be reported separately if the removal procedure is performed with a complete capsulectomy (19371) and if all contents are intracapsular. However, the placement of a new implant during the same operative session may be reported separately with code 19340 or code 19342 depending on whether a mastectomy is performed at the same time (19340) or previously (19342).
Codes 19340 and 19342 are used to report placement of a new implant or replacement of an existing implant within the mastectomy defect or reconstructed breast. The new guidelines indicate that "[p]ost-mastectomy breast reconstruction may be performed using a variety of techniques. An implant-based reconstruction involves placement of a device filled with fluid (eg, saline, silicone gel) to provide volume to the breast." The code selection of these two codes depends on the traditional definitions of immediate vs delayed reconstruction. Based on the new guidelines, "[i]n immediate reconstruction, an implant is primarily placed at the time of a mastectomy (19340). In delayed reconstruction, an implant is placed at any date separate from the mastectomy (19342). This includes placement of any new implant or replacement of an existing implant within the mastectomy defect or reconstructed breast."
Codes 19340 and 19342 include the creation of a prepectoral or subpectoral pocket, elevation of the pectoralis major and serratus anterior muscles, and elevation of rectus fascia and muscle, when performed to achieve muscle coverage of the implant. They also include any revisions of the mastectomy skin envelope and/or closure patterns. Elevating the pectoralis major and serratus anterior muscles for submuscular placement of a tissue expander does not constitute a "muscle flap."
For a biologic implant for soft tissue reinforcement, report code 15777, Implantation of biologic implant (eg, acelluar dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure). Do not report modifier 50 in conjunction with code 15777 for bilateral breast procedure. Instead, report code 15777 twice, if performed bilaterally. If a de-epithelialized "autoderm" flap is used instead of a biologic implant, this may be reported separately with adjacent tissue-transfer code(s) (14000-14350), as appropriate, and based only on the area of the transposed "autoderm" flap.
A new parenthetical note was added to indicate that code 19342 should not be reported in conjunction with code 19328 for removal of an implant in the same breast. For removal of tissue expander and replacement with a permanent breast implant, report code 11970. Do not report code 19342 for removal of a ruptured tissue expander. If a tissue expander has ruptured and is replaced with a breast implant, report code 11970. For removal of a ruptured tissue expander without replacement, report code 11971. Codes 19340 and 19342 may both be reported separately when flap reconstruction, including latissimus dorsi (19361), is performed. As indicated in the new guidelines, the removal of an intact breast implant for replacement is included in code 19342. Minor revisions to the capsule and/or soft tissue are considered inherent of the work of codes 19340 and 19342. Significant revisions to the peri-prosthetic capsule (19370) or a complete capsulectomy (19371) may be reported separately.
Code 19357 describes the insertion of a tissue expander and subsequent expansions in breast reconstruction and should not be reported for non-breast reconstruction procedures. Code 19357 may be reported separately, when performed with flap reconstruction. Prior to 2021, insertion of a tissue expander at the time of a flap reconstruction was reported with code 19340. In comparison, being able to separately report the placement of tissue expander, for example, with a latissimus dorsi flap (19361), enables more accurate reporting and properly reflects the additional postoperative work involved. Similar to codes 19340 and 19342, code 19357 includes creation of a prepectoral or subpectoral pocket, elevation of the pectoralis major and serratus anterior muscles, and elevation of the rectus fascia and muscle, when performed, to achieve muscle coverage of the implant. Code 19357 also includes any revisions of the mastectomy skin envelope or closure patterns.
Flap Reconstruction
The revised descriptor, guidelines, and new parenthetical notes now provide clear instructions for reporting an implant and/or tissue expander at the same time as a flap. Code 19361 describes breast reconstruction with a flap composed of the latissimus dorsi muscle, including some of the overlying skin and subcutaneous fat to reconstruct the breast mound. The following procedures may now be reported separately, in addition to code 19361, when performed: placement of a breast implant on the same day as a mastectomy (19340); breast implant on a day separate from mastectomy (19342); and tissue expander placement including subsequent expansions (19357).
The descriptor for code 19364 was revised to include examples of common free flaps, including free transverse rectus abdominis myocutaneous (fTRAM), deep inferior epigastric perforator (DIEP), superficial epigastric artery (SIEA), and gluteal artery perforator (GAP) flaps. Code 19364 continues to include the work of flap harvest; microsurgical anastomosis of one artery and two veins with use of an operating microscope (not separately reportable); flap inset as a breast mound; and donor site closure.
While there have been no significant changes to the code descriptors for the codes related to the pedicled TRAM techniques (19367-19369), these codes were converted to child codes of code 19361. According to the new parenthetical note that follows code 19369, codes 19361, 19364, and 19367-19369 include harvesting of the flap, closure of the donor site, and insetting and shaping of the reconstructed breast.
Revision of Peri-Implant Breast Capsule
Code 19370 was revised to describe any revision of a peri-implant capsule, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy. Prior to 2021, not all of these procedures could be accurately reported. As previously mentioned, an implant may temporarily be removed to access the capsule for revision; however, the removal and replacement of the same implant may not be separately reported. Similarly, the access incision made through the peri-implant capsule to exchange an implant or tissue expander does not constitute a "capsulotomy" as described in code 19370. However, when documentation clearly indicates extensive capsule work is performed during the placement of a new (size or shape) tissue expander or implant, it is appropriate to report code 19370 in conjunction with code 11970, 19325, 19340, 19342, or 19357. Code 19342 may be reported separately when placing a new size or shape implant at the same time as the capsule revision in a reconstructed breast.
Complete Capsulectomy
Code 19371 describes a complete capsulectomy and includes the removal of all intracapsular contents. Therefore, codes 19328 (removal of an intact breast implant) and 19370 (revision of peri-implant capsule) may not be reported in conjunction with code 19371. However, code 19342 may be separately reported for replacement of a new implant in breast reconstruction. The removal of extracapsular silicone in conjunction with a complete capsulectomy for a ruptured silicone implant is reported with code 10121, Incision and removal of foreign body subcutaneous tissues; complicated, in addition to code 19371.
Reconstructed Breast Revision
Code 19380 is reported when a revision is made to an already reconstructed breast that includes significant removal of tissue; re-advancement and/or re-inset of flaps in autologous reconstruction; or significant capsular revisions combined with soft-tissue excision in implant-based reconstruction. Per the breast repair and/or reconstruction introductory guidelines, "if a limited procedure is performed with a defined code (eg, scar revision), then the more specific code should be used." If code 19380 is reported, no other codes should be reported for work related to the breast envelope (ie, scar revision, mastopexy, liposuction, capsule modification, etc). Exchanging an implant for a new, different size, shape, or type of implant (19342), or autologous fat-grafting for increased volume or contour irregularities (15771, 15772), may be reported separately.
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