Wiki Breast Reconstruction and Modifier 59

[jhartung]

My doctor is charging the following codes for a breast reconstruction for one of our patient:

15734 - Muscle Myo/Fasciocutaneous flap-trunk
19371 - capsulectomy, periprosthetic breast
19328-59 - removal of intact mammary implant
19357-59 - breast recon. w/tissue expander, including subsequent expansion

The insurance company (MVP) paid for 15734 and 19371, but said that 19328 and 19357 are integral to 19371. I can understand how they could say that the removal of the implant would be considered part of the capsulectomy procedure, but I cannot find any CCI edits or any other documentation which states that 19357 is inclusive to ANY of these procedures. Am I missing something?

 

[BUDDY1983]

Code 19328 and code 19357 are MUTUALLY EXCLUSIVE. A modifier is allowed to override t

Code 19328 and code 19357 are MUTUALLY EXCLUSIVE. A modifier is allowed to override this relationship.


Modifier 59 is placed on both codes? Shouldn't it only be on the column 2 code 19327-59. You are right you would need a modifier to support seperate session, seperate site, bilateral. If he is doing in the same anatomical site than they would be inclusive and only pay the 19328.