AHA Coding Clinic® for HCPCS - 2023 Issue 1; Ask the Editor

Breast implant removal with acellular dermal matrix capsulectomy

A patient with a history of breast reconstruction now has a chronic wound of the left breast with impending implant exposure. Per the provider, the patient presented to surgery for left breast implant removal and capsulectomy. The existing inframammary fold incision was entered, followed by dissection down to the existing implant; the implant was extracted. The area was examined revealing the previously placed acellular dermal matrix (ADM) had poor take in the area of the chronic wound. Therefore, all nonintegrated ADM was excised and sent to pathology. The residual dermal matrix had incorporated onto the mastectomy flap and was left in place. The anterior chest wound was freshened and closed with sutures. The inframammary fold incision was closed in layers. The body of the operative report did not clearly indicate a capsulectomy; therefore, the provider was queried for supporting documentation. In the query response, the surgeon stated the removal of the ADM was considered a capsulectomy. For coding purposes, is removal of the ADM considered a capsulectomy? In this case, which CPT code is reported for the ADM and implant removal? ...

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