Anesthesia Coding Alert
Extent of Pectoralis Repair Dictates Code
Massachusetts Subscriber
Answer: CPT does not include a specific code for this procedure, which can make coding a challenge. Before attempting to code the procedure, find out about the extent of the procedure.
If the surgeon treated a closed injury, the best surgical code for the procedure is probably 21899 (Unlisted procedure, neck or thorax) with anesthesia code 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified).
If the patient had an open wound and pectoralis damage, begin with a complex repair code such as 21740 (Reconstructive repair of pectus excavatum or carinatum; open). You could report anesthesia for this more extensive procedure as 00474 (Anesthesia for partial rib resection; radical procedures [e.g., pectus excavatum]) or 01610 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla).
If you learn that the patient's humeral/axillary area was damaged, 01610 is probably the best code.
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