# Removal of TRAM flap



## Bwray (Dec 10, 2011)

If the patient had a simple mastectomy with TRAM flap reconstruction and returns to the OR for recurrent breast cancer involving the TRAM flap how would you code this?
OP Report reads:  Flaps were raised at the clavicle, parasternum and latissimus dorsi.  In order to get the breast off I had to get in the subpectoral plane, raise the breast off the muscle with Bovie cautery.  Once the breast was lateralized a complete three-level axillary lymphadenetomy was carrid out skeletonizing the axillary vein, thoracodorsal neurovascular bundle and the long thoracic nerve.  The nerves were proserved, I also used a Harmonic scalpel to track up along the axillary vien inferiorly up to where it penetrated the thoracic fascia.  Those nodes were submitted as the highest level III nodes.  The wound was closed in a T-fashion in order to get it closed.  Patient taken to recovery room in excellent condition having tolerated the procedure well.

CPT 21558 and CPT 38745 is what I found.
Any suggestions would be helpful.


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## Torilinne (Dec 11, 2011)

This one made me think!!! My first question was, "where, exactly, is the recurring cancer?"  It would be important to determine whether it has occurred in the flap or the remaining muscle, etc.  I found this excerpt from coding guidance provided by AHIMA:

"Some breast cancer patients have tumor recurrence after their mastectomy and it's especially important that the coder determine the exact site of the neoplasm. If no breast tissue remains, the tumor may actually involve the chest wall and should be coded accordingly. The physician may document "breast carcinoma" or "breast metastasis," but he or she may be referring to the cell type, not to the site of the neoplasm. Excisions of chest wall tumors are reported with CPT codes 19260, which includes rib excision, 19271, which includes plastic reconstruction but no mediastinal lymphadenectomy, and 19272, which includes plastic reconstruction and mediastinal lymphadenectomy."

I'm not sure if this helps or not but referencing the pathology report would also be helpful in gaining an understanding as to where the malignancy actually was found.  Good luck!

Tori
CPC, CGIC


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## Bwray (Dec 14, 2011)

*bwray*

Thank you for responding,  I've looked at the chest wall tumor excisional procedures but the surgeon doesn't remove a rib and doesn't do any plastic reconstruction (another surgeon does this)
As far as the path report: Left Breast Biopsy of a Lesion consistent with recurrent carcinoma (ductal carcinoma with lobular features)  _reason to remove TRAM FLAP._The path report for the surgery I posted: Left Breast Tram Site Excision, no residual tumor identified including negative margins.  _So the Biopsy removed all of the tumor._ 
 I'd like to have a new CPT code added to cover this type of surgery without a rib resection.

B Wray, CPC. CGSC


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