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General Surgery Coding Alert

Reader Question:

Implant Removal Is Part of Excision

Published on Mon May 28, 2007

Question: The patient underwent a modified radical mastectomy with removal of implant capsule. Can we charge for both the mastectomy and removal, or is the implant removal bundled?


Minnesota Subscriber


Answer: The National Correct Coding Initiative does, indeed, bundle implant removal (19328-19330) to mastectomy (19300-19307). The only exception might occur if the mastectomy and implant removal occur on different breasts. In this case, append modifier 59 (Distinct procedural service) to the removal and use modifiers LT (Left side) and RT (Right side) to designate on which side each of the procedures took place.
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