# Excision of dog ears with breast reconstruction



## jdibble (Sep 25, 2012)

Good morning all!

Hopefully someone can help me with this question - my plastic surgeon did a bilateral  tissue expander replacement with a permanant implant with extensive remodeling of the capsule and excision of dog-ears along the axillas.  She is billing 11970-50 and 19370-50-59.  The question I have is can she bill for the excision of the dog ears separately or would that be considered part of the Capsulotomy? And if the dog ears excision is billable, would I just code that as a complex closure?  Below is the note for review:

Thanks for all the help I can get!!! 


OPERATIVE FINDINGS:
This patient with breast cancer underwent previous bilateral mastectomies and reconstruction with AlloDerm and tissue expanders.  The patient's right side was contracted compared to the left side and the patient had bilateral dog-ears along the axillas.

DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was taken to the operating room, where a time-out was performed. The existing incisions were marked out and injected with local anesthesia. They were sharply created with a 15 blade through skin and subcutaneous tissue. The capsule was entered. The expanders were evaluated. The right expander was in good position and appeared to be smaller than the contralateral side indicating there was a slow leak.  There was no fluid within the capsule however. On the left side, the expander was removed without difficulty. On the right side in order to release the capsular contracture, the capsule was extensively remodeled circumferentially along the base of the capsule and then tangentially throughout the breast. On the left side, the left breast was over projected compared to the right side and capsular remodeling  occurred by scoring the capsule inferiorly to approximately the meridian and then tangentially in the superomedial and superolateral locations.  Both sites were copiously irrigated with saline and then hemostasis was checked and maintained with the Bovie.  Sizers were used and it was determined that the left side with 500 and the right side with 550 created a good match. The breasts were copiously irrigated with triple antibiotic solution and then the implants were placed after changing gloves and using a no-touch technique. On the left side the implant was a Natrelle implant reference 20-500, serial #17500780, and on the right side Natrelle style 45 reference 45-550 serial #16885013. The dog ears were marked out after closure was performed. Closure was performed in layers with deep 3-0 Vicryl running layer then 4-0 PDS deep dermals, and then 4-0 Monocryl as a final subcuticular closure and Dermabond.  Axillary ends of the incisions had dog ears which were marked and injected with local then excised sharply with a 15 blade.  The dog ears were closed in layers, a deep 4-0 PDS followed by running subcuticular closure and then Dermabond.   The patient tolerated the procedure well without complications. She was awoken in the operating room, taken to the recovery room in stable condition.  A bra and dry gauze were placed.  No intraoperative complications.


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## wcox (May 1, 2013)

I just make it part of the procedure. It is in the same surgery site and area is open so the closure you could bill becomes part of over all closure, which is component of cap work.


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