# Breast implant exchange/capsulotomy/augmentation



## martnel (Oct 30, 2012)

How would you code the following OP Note?  (11970/19370/19342) ??

PREOPERATIVE DIAGNOSIS:	Status post right mastectomy and reconstruction; breast asymmetry with hypoplasia.

POSTOPERATIVE DIAGNOSIS:	Status post right mastectomy and reconstruction; breast asymmetry with hypoplasia.

OPERATIVE PROCEDURE:	1.  Right implant exchange with capsulotomy.
			2.  Left subpectoral augmentation.

PRELIMINARY NOTE:  This is a woman had undergone immediate post mastectomy reconstruction with placement of a tissue expander.  She is now ready for implant exchange.  On the left side, she had quite a small breast.  Despite the fact that we had only planned to use a 300 cc implant for her right breast reconstruction, it would appear that she would need a small implant on the left.

DESCRIPTION OF PROCEDURE:   The patient was prepped and draped after satisfactory induction of general endotracheal anesthesia.  The old mastectomy scar was opened for a short distance.  The capsule was identified and opened with cautery.  The tissue expander was punctured and removed.  A separate dissection was done to remove the port and tubing from the lateral chest wall.

A 180 degree capsulotomy was then done, keeping the inferior 180 degree arc intact because she had a well-defined inframammary crease.  Particular attention had to be paid to release of the scar medially.  The pocket was irrigated.  A 300 cc sizer was placed and the wound closed loosely.

Our attention was turned to the contralateral side.  The preoperative markings were used as a guide.  We placed our inframammary crease incision at about 6 cm.  We made an incision measuring about 5 cm.  Dissection was taken down through the superficial fascia until the chest wall fascia was identified.  This was used for access to the inferomedial costal and sternal origins of the pectoralis which was released to a point that corresponded to a point at about eight o'clock.  Dissection was then taken laterally, leaving the serratus on the chest wall and creating a large subpectoral pocket.  Hemostasis was acquired with bipolar cautery.  We placed a 150 cc sizer into that pocket and closed the wound loosely.  The patient was sat up and this appeared to be a good result for her permanent implant.

A 300 cc, high-profile, round implant was selected for the right and a 150 cc, moderate plus profile was selected for the left. These were inserted into the respective cavities.  Closure was done with Vicryl and nylon.  Sterile dressings were applied.  The patient tolerated the procedure well.


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## martnel (Nov 1, 2012)

Since I am new to Plastic Surgery, I was really hoping to get some help here.... Anybody?  Please, any input would be highly appreciated!  Thanks!


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## jdibble (Nov 30, 2012)

Code 11970 includes a capsulotomy unless their is significant capsule work done and the documentation must support this extra work in order to also code the 19370.  You would also need to attach a 59 modifier to this code as the capsulotomy is considered the appoach.  Oh, and if it is done bilaterally, don't forget the 50 modifier.

I have copied the following from CPT assistant which explains how to code and also the description of a capsulotomy so you can determine if this capsulotomy was extensive and beyond that for the approach.  It also explains when you would use 19342 instead.

*Tissue Expansion * 

The most common technique of breast reconstruction involves placement of a tissue expander, an uninflated balloon-like device, beneath the skin and chest muscle. The expander, which may be temporary or permanent, can be inserted following mastectomy (immediate) or at a later date (delayed). Through a small injection port under the skin, saline is injected into the expander over a period of weeks or months, gradually filling it to the desired size while stretching the overlying skin. Code 19357, Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion, is used to report this procedure. The same code is used regardless of whether the procedure is immediate or delayed. This code is global and includes routine postoperative visits and subsequent expansions during the assigned postoperative global surgery period (eg, 90 days). When visits for expansions are necessary beyond the global period, they may be reported on a service-by-service basis. 

If a temporary tissue expander has been used, it is removed after the skin has stretched sufficiently and replaced with a permanent breast prosthesis during a second operation. This procedure is generally coded 11970, Replacement of tissue expander with permanent prosthesis. Code 11970 is global and includes removal of the temporary expander, which is not to be reported separately. In certain instances, considerable capsular adjustments are necessary to allow proper placement of the prosthesis within the fibrous capsule that has formed around the expander, and with appropriate documentation in the operative report, code 19342 is sometimes used instead of 11970. 

When a permanent tissue expander has been used, it is left in place at the conclusion of the expansion process. A second operation is not required. 


*19370 *-  An open periprosthetic capsulotomy on the breast is done by making an incision in the skin of the breast, at the site of a mastectomy scar, in the skin fold beneath the breast, or around the nipple. The physician uses a cautery knife to cut into the area of fibrous scarring associated with a breast implant. Incisions are made into the scar (contracted capsule) to cut around its circumference and enlarge the pocket in which the prosthesis is placed. Loosening the capsule relieves pain and tightness caused by the contracture. No tissue is removed. The incision is repaired with layered closure. 

Hope this helps!


CPT Assistant*©*Copyright 1990-2012, American Medical Association. All rights reserved.


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## Mconway03 (Jan 3, 2013)

I would use 11970 and 19370 for the right side and code 19325 for the left side.  11970 and 19370 would code for the replacement with perm implant along with the capsulotomy.... use 19325 for the making the right side symetrical with implant.


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