“Coding the Reconstruction” Follow Up to Dr. DiMercurio’s presentation Linda Corrigan, MHE, RHIT, CTR Cancer Registry Program Manager Washington Adventist Hospital

And the operative report says… Right simple mastectomy, reconstruction with implant plus alloderm. You would code it as Simple mastectomy 43 without removal of uninvolved contralateral breast with reconstruction, NOS 44 without removal of uninvolved contralateral breast with tissue 45 without removal of uninvolved contralateral breast with implant 46 without removal of uninvolved contralateral breast with combined tissue & implant

ANSWER PER FORUM: 46 without removal of uninvolved contralateral breast with combined tissue & implant The alloderm is donor tissue. Use code for combined - implant & tissue.

And the operative report says… Left MRM, right simple mastectomy with immediate recon bilat breasts with adjustable implants to be utilized for expansion and acellular dermal matrix. In the op reports it states two sheets of AlloMax You would code it as MRM 57 with removal of uninvolved contralateral breast reconstruction, NOS 58 with removal of uninvolved contralateral breast & Tissue 59 with removal of uninvolved contralateral breast & Implant 63 with removal of uninvolved contralateral breast Combined Tiss & Imp

ANSWER PER FORUM: 59: with removal of uninvolved contralateral breast & Implant The surgical procedure to primary site is MRM with removal uninvolved contralateral breast. Alloderm & allomax are not the same thing

And the operative report says… Left MRM, first stage reconstruction with immediate placement of tissue expander with Alloderm sling You would code it as MRM 53 without removal of uninvolved contralateral breast reconstruction, NOS 54 without removal of uninvolved contralateral breast & Tissue 55 without removal of uninvolved contralateral breast & Implant 56 without removal of uninvolved contralateral breast Combined Tiss & Imp

NOT ON FORUM, YOUR THOUGHTS: 54: without removal of uninvolved contralateral breast & Tissue (because no implant happened during this procedure) OR 56: without removal of uninvolved contralateral breast Combined Tiss & Implant (because it states “first stage” assume an implant will be placed at a later time)

And the operative report says… Bilateral total mastectomies with removal of sentinel and axillary lymph nodes on the left, immediate reconstruction of bilateral breasts with adjustable implants for tissue expansion and bilateral dermal matrix." You would code it as Total Mastectomy 47 with removal of uninvolved contralateral breast reconstruction, NOS 48 with removal of uninvolved contralateral breast & Tissue 49 with removal of uninvolved contralateral breast & Implant 75 with removal of uninvolved contralateral breast Combined Tiss & Imp

ANSWER PER FORUM: 49, Total mastectomy w/removal of uninvolved contralateral breast w/reconstruction - Implant