AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2023 Issue 2; Ask the Editor
Inframammary Fold Adjacent Tissue Transfer and Deep Inferior Epigastric Perforator Flap Breast Reconstruction
A patient who is status-post bilateral mastectomy secondary to breast cancer presents for a delayed bilateral breast reconstruction utilizing a deep inferior epigastric perforator (DIEP) flap along with a Ryan flap inframammary fold (IMF) adjacent tissue transfer. Once the DIEP flap portion of the procedure was completed, a dissection to the inframammary fold was performed. Dissection proceeded caudal to this to create a thoracoabdominal flap. The posterior capsule was scored at the desired IMF position. The flap was advanced and secured to the posterior chest with multiple sutures. This improved the shape and the position of the IMF. This adjacent tissue transfer was required on both the right and the left breasts and defined the IMF. The flaps were then inset appropriately with sutures. The mastectomy skin was evaluated and skin was excised as appropriate bilaterally. The entire lower half of both breast/chest skin areas were removed. This involved removing the scar and the previous wounds. Electrocautery was used to create a step-off around the flap skin paddle. Layered closure was then performed. What is the appropriate code for the inframammary fold (IMF) adjacent tissue transfer (Ryan flap) when performed in conjunction with a DIEP flap for breast reconstruction? ...
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