AHA Coding Clinic® for HCPCS - 2021 Issue 2; Ask the Editor

Goldilocks reconstruction

A patient with left breast cancer presented for bilateral skin and nipple sparing mastectomies with Goldilocks reconstruction. After the removal of the breast tissue, dermal autografts/flaps were created and tacked superomedially to create breast mounds. The medial inferior dermal flap was tacked on the pectoralis muscle in the upper inner quadrant and the lateral inferior dermal flap was tacked on the pectoralis in the central portion of the pectoralis muscle. The edges were brought together with staples creating small breast mounds consisting of dermal graft under the mastectomy incision prior to closing the mastectomy flaps. What is the correct code assignment for a mastectomy with Goldilocks reconstruction? ...

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