I have a physician who will do a fasciocutaneous advancement flap to reconstruct the lateral breast mound (15734) and then also insert pre-pectoral tissue expanders (19357) during the same surgical session. They do the fasciocutaenous flap due to the amount of dissection that was performed during the mastectomy the patient had, the dissection had exceeded the anatomic boundaries of the breast mound for adequate oncologice resection. I am getting an NCCI edit for the 15734 being inclusive to the 19357. Would it be ok to add a 59 modifier onto the 15734?
This is the physician's documentation for the flap:
"...The skin flaps were evaluated and noted to be viable, with healthy bright red blood from the skin edges, no areas of congestion, and appropriate capillary refill in both the superior and inferior mastectomy flaps. Hemostasis was then achieved in the breast pocket using the Aquamantys bipolar device and the Bovie electrocautery. . Next, Two fifteen French drains were placed in the breast pocket 1 into the axilla laterally and 1 placed into the breast pocket. The drains were sutured to the skin using 2-0 nylon suture. Next, we determined the inferior extent of the breast pocket and marked the inframammary fold to correlate with the patient's native breast markings for symmetric reconstruction. The soft tissue/dermal matrix was obtained, this was washed with sterile saline solution followed by antibiotic solution containing vancomycin gentamicin and sterile saline. After soaking the dermal matrix in saline solution, we turned our attention to correction of the lateral breast mound. Given the necessity of dissection during mastectomy which exceeded the anatomic boundaries of the breast mound for adequate oncologic resection, a lateral thoracic advancement fasciocutaneous flap was performed to recreate the lateral breast mound anatomy and prevent malposition of the reconstruction. The flap was designed based on perforators from the thoracodorsal artery system, it was elevated using the Bovie electrocautery, at the level of the lateral chest wall and axillary muscle fascia. The flap was advanced onto the chest wall and secured laterally using multiple running 0 Stratafix sutures to create the lateral breast border that had been marked preoperatively based on the patient's preexisting anatomy and anterior axillary line., c Next, we continued with inset of the dermal matrix along the inferior, medial, and lateral breast border again using PDS suture,, the Dermal matrix was inset into the inframammary fold using multiple vertical mattress 2-0 PDS sutures. The medial portion of the dermal matrix was also inset into the breast pocket to the 4:00 position. Next, we chose a tissue expander that correlated with the patient's breast pocket measurements: Sientra Allox2 expander was chosen. This was obtained from the circulating nurse, the serial number was recorded, and the tissue expander was then deflated of all air, and placed into a bath of antibiotic solution. We then . Following completion of the dermal matrix inset, the breast pocket was washed multiple times using sterile saline solution followed by triple antibiotic solution and chlorhexidine containing surgical irrigation. Next the chest wall was re-prepped and new towels were used to redrape, all participants in the case then donned new surgical gloves. The tissue expander was removed from the antibiotic solution bath, was placed into the chest cavity behind the dermal matrix sling, the tabs of the tissue expander were used to fix the expander into position that would allow for adequate expansion of the lower pole of the breast and secured the expander in the appropriate position. Three points of fixation using the tabs on the expander were performed with 2-0 PDS suture. The tissue expander was filled to 500cc, which allowed for a tension-free approximation of the skin edges. Next skin closure was performed in multiple layers beginning with a 3-0 PDS suture for the deep and dermal closure layers, next a 4-0 Monocryl suture was used for skin approximation, this was then covered using surgical skin adhesive...."
This is the physician's documentation for the flap:
"...The skin flaps were evaluated and noted to be viable, with healthy bright red blood from the skin edges, no areas of congestion, and appropriate capillary refill in both the superior and inferior mastectomy flaps. Hemostasis was then achieved in the breast pocket using the Aquamantys bipolar device and the Bovie electrocautery. . Next, Two fifteen French drains were placed in the breast pocket 1 into the axilla laterally and 1 placed into the breast pocket. The drains were sutured to the skin using 2-0 nylon suture. Next, we determined the inferior extent of the breast pocket and marked the inframammary fold to correlate with the patient's native breast markings for symmetric reconstruction. The soft tissue/dermal matrix was obtained, this was washed with sterile saline solution followed by antibiotic solution containing vancomycin gentamicin and sterile saline. After soaking the dermal matrix in saline solution, we turned our attention to correction of the lateral breast mound. Given the necessity of dissection during mastectomy which exceeded the anatomic boundaries of the breast mound for adequate oncologic resection, a lateral thoracic advancement fasciocutaneous flap was performed to recreate the lateral breast mound anatomy and prevent malposition of the reconstruction. The flap was designed based on perforators from the thoracodorsal artery system, it was elevated using the Bovie electrocautery, at the level of the lateral chest wall and axillary muscle fascia. The flap was advanced onto the chest wall and secured laterally using multiple running 0 Stratafix sutures to create the lateral breast border that had been marked preoperatively based on the patient's preexisting anatomy and anterior axillary line., c Next, we continued with inset of the dermal matrix along the inferior, medial, and lateral breast border again using PDS suture,, the Dermal matrix was inset into the inframammary fold using multiple vertical mattress 2-0 PDS sutures. The medial portion of the dermal matrix was also inset into the breast pocket to the 4:00 position. Next, we chose a tissue expander that correlated with the patient's breast pocket measurements: Sientra Allox2 expander was chosen. This was obtained from the circulating nurse, the serial number was recorded, and the tissue expander was then deflated of all air, and placed into a bath of antibiotic solution. We then . Following completion of the dermal matrix inset, the breast pocket was washed multiple times using sterile saline solution followed by triple antibiotic solution and chlorhexidine containing surgical irrigation. Next the chest wall was re-prepped and new towels were used to redrape, all participants in the case then donned new surgical gloves. The tissue expander was removed from the antibiotic solution bath, was placed into the chest cavity behind the dermal matrix sling, the tabs of the tissue expander were used to fix the expander into position that would allow for adequate expansion of the lower pole of the breast and secured the expander in the appropriate position. Three points of fixation using the tabs on the expander were performed with 2-0 PDS suture. The tissue expander was filled to 500cc, which allowed for a tension-free approximation of the skin edges. Next skin closure was performed in multiple layers beginning with a 3-0 PDS suture for the deep and dermal closure layers, next a 4-0 Monocryl suture was used for skin approximation, this was then covered using surgical skin adhesive...."