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Friday, December 15, 2017

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Gittleman’s Coding Corner: How to code for skin-sparing or nipple-sparing mastectomy?

Mark Gittleman M.D.

Answer: CPT code 19303 (mastectomy; simple or complete) is the appropriate code. This includes nipple or skin-sparing mastectomy. (In CPT, there is no distinction between simple and total mastectomy). Many will argue that there is more work involved in skin-sparing/nipple-sparing mastectomy. However, we need to recognize that these procedures do not typically involve wound closure, as that is done by the plastic surgeon performing the immediate reconstruction procedure. If sentinel node biopsy is also performed, then in addition to 19303, use 38900 (intraoperative mapping of sentinel node; includes injection of non-radioactive dye, when performed), and 38525-51 (deep axillary node biopsy).

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