Documenting Mastectomy with ICD-10 and CPT Codes

Hi everyone and welcome back to our podcast series. Today’s podcast is about coding for mastectomy and using the correct ICD-10 and CPT codes.

Most women with breast cancer choose mastectomy, the surgery to remove all breast tissue (including the nipple and the areola) from one or both breasts. Primarily performed to treat or prevent breast cancer, mastectomy is normally carried out to remove existing cancerous cells within the breast and thereby reduce the potential for breast cancer to spread. The procedure is often done when a woman cannot be treated with breast-conserving surgery or a lumpectomy in which only the tumor is removed from the breast. Deciding between a mastectomy and a lumpectomy can be difficult and hence women with breast cancer can decide along with their surgeon whether to be treated with a lumpectomy or a mastectomy. Oncologists and plastic surgery specialists performing mastectomy and other treatment procedures must report the same on their medical claims using the correct medical codes. ICD-10 codes for this procedure start at Z90.1 and go to Z90.13. CPT codes start at 19301 and go to 19307.

A mastectomy may be a treatment option for many types of breast cancer, including Ductal carcinoma in situ (DCIS), Stages I and II breast cancer, Stage III breast cancer, and inflammatory breast cancer.

Procedure and Risks

Typically, a mastectomy is performed under general anesthesia and hence patients are not completely conscious during the surgery. The procedure begins with your surgeon making an elliptical incision around your breast. The breast tissue is removed and, depending on your procedure, other parts of the breast also may be removed. An IV line is used to administer medicines that may be required during surgery.

There are different types of mastectomy to deal with different medical situations, which include total, double, skin-sparing, nipple-sparing, modified radical, and radical mastectomy.  The type of mastectomy procedure performed will depend on a wide range of factors such as age of the patient, size, stage and grade of the tumor, menopause status, the involvement of lymph nodes, and the general health of the patient. The potential risk factors include –

• Pain
• Swelling
• Shoulder pain and stiffness
• Numbness, particularly under your arm, from lymph node removal
• Infection
• Formation of hard scar tissue at the surgical site
• Buildup of blood in the surgical site, and
• Bleeding

Regardless of the type of mastectomy done, the breast tissue and lymph nodes that are removed will be sent to a laboratory for analysis.

Before undergoing a mastectomy, patients need to meet their surgeon and anesthesiologist to discuss about the surgery, including the reasons for and risks of the surgery, and determine the plan for your anesthesia. An important point to discuss is that whether patients require breast reconstruction to be done immediately after, while still being anesthetized. For patients who are undergoing breast reconstruction at the same time as a mastectomy, it is important to consult a plastic surgeon before the surgery.

Plastic surgery specialists and oncologists performing breast reconstruction after mastectomy must use the relevant diagnosis and procedure codes to bill the procedure. The CPT codes for breast reconstruction surgery post-mastectomy include: 11920, 11921, 11922, 11970, 11971 and 19499.

When preparing for mastectomy, patients must follow certain instructions from the physicians and these include –

• Inform your physicians about the medications, vitamins or supplements that you are consuming,
• Stop consuming medications a week before surgery as these can increase the risks of excessive bleeding.

As soon as the mastectomy procedure is complete, the patient will be closely monitored wherein their heart rate, blood pressure, level of pain and feelings of nausea will be evaluated and medicated as appropriate. The average period of hospital stay after the procedure is generally 3 days. However, if reconstructive surgery is completed in the same surgery, the time of hospital stay may be slightly longer.

The time of recovery will differ from one individual to another and may depend on the type of procedure performed. In most cases, patients can resume normal work within 3-6 weeks. However, the recovery time will be longer if reconstruction is performed.

I hope this helps, but always remember that documentation as well as a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank for joining me and stay tuned for my next podcast.