Wiki Need coding advice.

[JWEILER]

The surgeon in my office did a mastectomy on a patient 10 years ago. The patient had reconstructive surgery at that time. She has now had a recurrence and had to have another mastectomy and removal of her implants, not sure if to use mastectomy code or excision of tumor w/flap closure.

 

[OCD_coder]

You are not giving enough information to help you. Did the surgeon excise a tumor?

You honestly can't have another mastectomy if the mammary glands were removed once all ready.

 

[ASH527]

If the patient has already had a mastectomy & reconstructive surgery I would think that the mastectomy code isn't what you want - ? code 19328 to remove the implant, as it sounds as if she has already had a radical mastectomy - I agree that you need more clinical info before selecting any codes

 

[JWEILER]

I agree with you and that is what I told the physician. The information she gave me is minimal. The patient had recurrence to the mastectomy site. She is also calling it a chest tumor. She marked an excision benign lesion w/left 12cm intermediate closure and excision malignant lesion w/15cm flap closure. She also stated the obvious which is that the implants needed to be removed from her previous reconstructive surgery.