jfolz
Networker
I code for a hospital outpatient facility. We have two differing schools of opinion in the office. I have combed the internet and cannot find a definitive answer for this question. I am specifically looking for official sources to provide with whatever answer(s) I may receive.
Here are the facts we agree on:
1. For CPT 19342, the procedure is, " Insertion or replacement of breast implant on separate day from mastectomy".
2. There is a CPT Assistant from Sept 2022 that states (in part), ".... In cases of previous breast augmentation with an implant (typically these would be aesthetic cases but are also performed as a symmetry procedure for patients with breast cancer reconstruction or other rare situations), code 19325, Breast augmentation with implant, would be used to report the replacement of an implant instead of code 19342."
What we cannot agree on at this point is what constitutes a "mastectomy" for this CPT?
One school of thought is that a mastectomy is just that- a removal of the breast tissue from the patient in total, one or both sides as specified in the record. The CPT assistant (provided above) could also be used to argue that the CPT definition of "mastectomy" for this CPT definition is not including partial mastectomies (lumpectomies) because this CPT assistant provides information that seemingly proves that not all procedures that involve breast surgery for cancer removal are considered mastectomies when it mentions these cases may, "also be to improve symmetry or patients with breast cancer reconstruction or other rare situations".
The other party argues simply that CPT 19342 does not specify that a previous TOTAL mastectomy is necessary to use that CPT code, only that a "mastectomy" of some sort has happened in the past and that would include a lumpectomy.
Here is a brief overview of the case that sparked our discussion: Pt had a (one side only) lumpectomy in the past and has also undergone a bilateral reduction to improve symmetry between the native breast and the breast that was affected by cancer. It is several years out from the lumpectomy and the reductions and now the patient is coming in for bilateral implants. Is this case to be coded as 19342 or 19325? How would you code this case and why?
I'm honestly surprised that the question has not been asked/ answered anywhere that I have been able to find it.
I would really appreciate any insights or discussion on the matter. TIA!
Here are the facts we agree on:
1. For CPT 19342, the procedure is, " Insertion or replacement of breast implant on separate day from mastectomy".
2. There is a CPT Assistant from Sept 2022 that states (in part), ".... In cases of previous breast augmentation with an implant (typically these would be aesthetic cases but are also performed as a symmetry procedure for patients with breast cancer reconstruction or other rare situations), code 19325, Breast augmentation with implant, would be used to report the replacement of an implant instead of code 19342."
What we cannot agree on at this point is what constitutes a "mastectomy" for this CPT?
One school of thought is that a mastectomy is just that- a removal of the breast tissue from the patient in total, one or both sides as specified in the record. The CPT assistant (provided above) could also be used to argue that the CPT definition of "mastectomy" for this CPT definition is not including partial mastectomies (lumpectomies) because this CPT assistant provides information that seemingly proves that not all procedures that involve breast surgery for cancer removal are considered mastectomies when it mentions these cases may, "also be to improve symmetry or patients with breast cancer reconstruction or other rare situations".
The other party argues simply that CPT 19342 does not specify that a previous TOTAL mastectomy is necessary to use that CPT code, only that a "mastectomy" of some sort has happened in the past and that would include a lumpectomy.
Here is a brief overview of the case that sparked our discussion: Pt had a (one side only) lumpectomy in the past and has also undergone a bilateral reduction to improve symmetry between the native breast and the breast that was affected by cancer. It is several years out from the lumpectomy and the reductions and now the patient is coming in for bilateral implants. Is this case to be coded as 19342 or 19325? How would you code this case and why?
I'm honestly surprised that the question has not been asked/ answered anywhere that I have been able to find it.
I would really appreciate any insights or discussion on the matter. TIA!