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

Excision of redundant tissue post-mastectomy

A patient underwent bilateral mastectomies without reconstruction. She now presents for bilateral excision of redundant and excessive skin. She also had bilateral seromas, which contributed to the formation of the excess tissue. The right breast skin and soft tissue were anesthetized. An elliptical incision was made and the redundant tissue was excised. The dissection was carried down to the anterior chest wall. The excised area measured 6 cm. The redundant area of the right axillary region was excised and the wound measured 18 cm. The deep tissue wounds at both sites were closed in layers. The skin and soft tissue of the left mastectomy site was anesthetized. She developed a painful cicatrix medially. An elliptical incision was made and the 6 cm cicatrix was excised. Only medial breast tissue required excision. Her breast tissue remaining on the left was without diagnostic abnormality. The deep tissue wound was closed in layers. All three deep wounds were closed and dressed.How is the excision of redundant skin status-post mastectomy coded for a patient who has not undergone prior breast reconstruction? ...

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