General Surgery Coding Alert

Question: When our surgeon performs second stage breast reconstructions, he often performs a capsulectomy as well. Should we consider these different procedures, even though they're at the same site through the same incision? Can we code both using 11970 and 11971-59? Texas Subscriber

Answer: No, you should not consider these separate procedures. The situation you describe does not meet the standard for separate billing. The Correct Coding Initiative (CCI) edits bundle 11970

(Replacement of tissue expander with permanent prosthesis) and 11971 (Removal of tissue expander[s] without insertion of prosthesis) as a mutually exclusive pair. Although the CCI modifier indicator allows you to unbundle the pair, when appropriate, your situation does not meet the criteria of separate body site or operative session to warrant overriding the edit pair using modifier 59 (Distinct procedural service).

If the capsulectomy is extensive enough to truly involve significant additional time or work, you should document that clearly and add modifier 22 (Increased procedural service) to the claim. Otherwise, you should include the work of incising the capsule in the breast reconstruction procedure and report only 11970.