AHA Coding Clinic® for HCPCS - 2026 Quarter 2; Ask the Editor
Breast Implant Revision
A patient with a history of right breast cancer previously underwent right mastectomy with immediate implant-based reconstruction and subsequent left breast implant augmentation mastopexy for symmetry. The patient presented for revision due to excessive breast size. Attention was directed to the left breast. The nipple-areolar complex was marked for preservation, and a vertical mastopexy pattern was designed. De-epithelialization was performed. Dissection was carried through subcutaneous and glandular tissue to the level of the capsule. The existing left breast implant (140 cc) was identified and removed intact; no replacement implant was inserted. Following implant removal, the breast remained enlarged. Tissue excision was performed from the inferior medial, inferior, inferior lateral, lateral, and superior lateral portions of the breast. A total of approximately 125 grams of breast tissue was removed. Mastopexy was performed with elevation and rearrangement of breast tissue flaps, and repositioning of the nipple-areolar complex. The nipple-areolar complex remained viable throughout the procedure. Incisions were closed in layered fashion. What are the appropriate CPT codes for the left breast procedures? ...
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Article Overview
This article covers a surgical breast revision case in a patient with prior mastectomy and implant-based reconstruction, followed by contralateral augmentation mastopexy for symmetry. It focuses on the operative steps involved in implant removal, tissue excision, and breast reshaping, making it relevant to surgical coders, plastic surgery staff, and reimbursement teams reviewing breast reconstruction and revision documentation.
Why This Topic Matters
Breast revision procedures often combine multiple operative components that may affect code selection and documentation review. Understanding the scope of the surgery helps coders and auditors recognize the clinical context and the types of services documented in the operative note.
What You Will Learn
- How a breast implant revision case is described in operative documentation.
- What broad surgical components may be present in a combined breast revision procedure.
- How prior reconstruction and symmetry procedures can frame the clinical context of a revision case.
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Who Should Read This
- Medical coders
- Plastic surgery staff
- Clinical documentation specialists
- Revenue cycle professionals
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