Wiki CPT 19380 inconsistent with Dx 611.89 - I am getting denials from Humana

[CharliBelle]

I am getting denials from Humana stating CPT 19380 "Revision, Reconstructed" cannot be billed with diagnosis 611.89 OTHER SPECIFIED DISORDERS OF BREAST. Could Humana possibly be looking for the underlying cause of the deformity? Should 19380 be billed with V10.3 PERSONAL HX MALIG NEOPLASM BREAST as the primary diagnosis instead?

 

[mitchellde]

if the reason for the procedure is to reconstruct the breast due to mastectomy due to breast cancer then you need to use the V51.- code first listed with the V10.3 secondary. To have a reconstruction following mastectomy is not a disorder of the breast.

 

[ohinslh]

19380

We get this paid with the code 612.0 (deformity of reconstructed breast) and history code V10.3

 

[Nichole9288]

We use 612.0 and V10.3 also without any trouble.

 

[magnolia1]

Often times, revision of reconstructed breast (CPT 19380) is done due to an
issue with asymmetry.
In the case of a mastectomy with subsequent reconstruction where the physician is documenting asymmetry as the reason for current surgery, dx code would be 612.1

Keep in mind that the patient may still be receiving some form of treatment for the cancer
so review your documentation for 174.X versus V10.3

 

[mitchellde]

We get this paid with the code 612.0 (deformity of reconstructed breast) and history code V10.3

612.0 is not used for a reconstruction following mastectomy, that code is used to correct a deformity after a reconstruction has already occurred.
The appropriate first listed code for a reconstuction after a mastectomy is the code that was created specifically for this purpose:
V51.0 Encounter for breast reconstruction following mastectomy

 

[tommilee57]

I have a case where breast implants were removed and replaced due to the implants were migrating laterally when the patient was supine. The actual code I seem to come up with is 19340 immediate insertion of implant (in reconstruction). I have read that this has to be done in the same session as a mastectomy however that is not my/others interpretation of the descriptor. CPT 19380 does not include the removal of previous/replacement of the new implant. Any suggestions? Actually I read other guidance that indicated when an implant is placed the correct code to report is 19340 and not the 19380 due to it is a straightforward procedure and implant is not included........