# Oncoplastic Breast Reconstruction



## JBowyer (Feb 20, 2013)

'14000' -- for Oncoplastic Breast Reconstruction
This somewhat new method of breast reconstruction that removes the tumor and also repair the defect left by the tumor removal.  We have been coding 14000-14001 for this procedure, but I was told that based on the article in the AAPC Coding Edge February 2012 ATT/R Cover Story -- "Optimize Adjacent Tissue Transfer/Rearrangement Reimbursement" that this was not correct.  Can someone confirm and/or show me where/how this CPT would not be correct?  I have bonded the area of the operative report to show this procedure. Thanks

Patient has Lumpectomy and surgeon performs adjacent tissue transfer from surrounding area to cover and correct defect, would 14000 be correct code for this? Per the code description of CPT 14000: "The physician transfers or rearranges ajacent tissue to repair traumatic or surgical wounds of the trunk. This includes, but is not limited to, such arrangement procedures as Z-plasty, W-plasty, ZY-plasty, or tissue transfers such as rotational or advancement flaps." I have posted operative report below. THANK YOU for your assistance.

PREOPERATIVE DIAGNOSIS: Persistent right breast carcinoma (positive inferior margin on most recent right breast excisional biopsy).

POSTOPERATIVE DIAGNOSIS: Persistent right breast carcinoma (positive inferior margin on most recent right breast excisional biopsy).

PROCEDURES PERFORMED:
1. Reoperative right breast lumpectomy with frozen sections.
2. Oncoplastic right breast reconstruction.
3. Intraoperative fluorescent cutaneous angiography. 

ANESTHESIA: General endotracheal anesthesia. 

ESTIMATED BLOOD LOSS: 5 mL or less. 

IV FLUIDS: 1400 mL IV crystalloid fluid.

DRAINS: None. 

COMPLICATIONS: None apparent. 

INDICATIONS FOR SURGERY: This is a 52-year-old female who previously underwent a very large resection of her right inferior breast for invasive breast carcinoma. She also underwent what was purported to be a right axillary lymph node dissection; however, this specimen contained no actual lymph nodes. She subsequently presented to ........where she underwent right axillary lymph node dissection and excisional biopsy of a new right breast mass (adjacent to her prior "lumpectomy" scar). The patient was found to have extensive axillary nodal involvement. Additionally, the frozen section evaluation of her right breast mass was reported as negative for malignancy. However, upon final permanent sections, residual/recurrent breast carcinoma was found within this excisional biopsy specimen. The inferior margin of the specimen was focally positive for malignancy. Therefore, she is to undergo reexcision of this right breast site of residual/recurrent breast carcinoma. 

DESCRIPTION OF PROCEDURE: The proposed operative site was marked in the preoperative area by me. The patient was then taken to the operating room where general endotracheal anesthesia was induced without difficulty. The right breast was prepped and draped in the usual sterile fashion. The previously placed right axillary Jackson-Pratt drain was removed at this time. A "time-out" was called and all members of the operating team agreed as to the identity of the patient and the procedures to be performed. 

The prior right breast lumpectomy/biopsy scar was sharply excised with 3-mm circumferential margins. This specimen was sent for frozen section which returned as "no malignancy seen." Following this, the prior excisional biopsy and oncoplastic reconstruction site were opened. The large cavity within the right breast was then copiously irrigated with antibiotic solution. A 2-cm thick veneer of breast tissue was then excised from the inferior margin of this lumpectomy cavity, down to the chest wall. Orientation sutures were placed, and the specimen was sent to Pathology for frozen section evaluation. Once again, this specimen returned as "no malignancy seen." Finally, due to a somewhat close margin (3 mm), the superior margin of the lumpectomy/biopsy cavity was also tangentially excised and sent for frozen section. This specimen as well returned as "no malignancy seen." 

*The resulting quadrantectomy defect in the inferior-median right breast was then assessed. After this assessment, multiple full-thickness pedicles of vascularized breast parenchyma were sharply mobilized and secured within the central portion of this breast defect using interrupted 3-0 Vicryl sutures. During the mobilization of these pedicles, multiple medium titanium clips were placed for marking purposes to assist the radiation oncologist with adjuvant radiation therapy planning. Additional mobilization of the superior and inferior skin flaps of the right breast, including the tethered inframammary fold, was performed to improve cosmesis. Following this, inverted, interrupted 3-0 Vicryl sutures were used to close the deep dermis. Local anesthetic was then injected into the skin around the incision and then, using a soft Angiocatheter into the reconstructed lumpectomy/biopsy cavity as well. Finally, the superficial dermis was closed with a running subcuticular 4-0 Monocryl suture. *

The superior skin flap appeared somewhat dusky at this time. Therefore, intraoperative fluorescent cutaneous angiography was performed, using the SPY Elite device. A total of 10 ml of isocyanine green dye was administered by the anesthesiologist, under my supervision. Laser-assisted imaging of the right breast was then performed in real time (intraoperative fluorescent cutaneous angiography). This intraoperative imaging study revealed normal perfusion of the superior and inferior right breast skin flaps.

DermaBond cement was then applied to seal this incision. Additional DermaBond cement was placed over the prior right axillary drain site. A final sponge, needle and instrument count was confirmed to be correct. There were no apparent intraoperative complications. Therefore, anesthesia was reversed and the patient was extubated. She was taken to the recovery room awake, alert, with stable vital signs.


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