General Surgery Coding Alert

Question: How should I code the exchange of a tissue expander for a different type of tissue expander during the global period of the original reconstruction procedure? The surgeon performed a capsulotomy only for access to the expander.

Vermont Subscriber

Answer: You should report 19371 (Periprosthetic capsulectomy, breast) and 19357 (Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion). Modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) is probably appropriate on both codes, although you don't mention why the expander is being removed so it's hard to be sure.

Code 19371 includes the removal of a breast implant. "It does not include, however, reinsertion of that breast implant or a new breast implant," according to an August 1996 CPT Assistant article. Remember: If your surgeon is simply performing an expansion, you cannot report that service. Code 19357 includes routine postoperative visits and subsequent expansions during the 90-day global period. If the tissue expander is temporary, however, you should report its removal and replacement with a permanent prosthesis using 11970 (Replacement of tissue expander with permanent prosthesis).