May 11, 2017

Question:
I placed a permanent breast implant after removing a tissue expander including a capsulotomy on the right side.  At the same operative session, on the same side, I harvested fat from the thigh (via liposuction) and placed it in to the superior pole breast defect.   These are the codes that I have picked: 19340 (immediate insertion of breast implant), capsulotomy (19370), 19380 (revision of reconstructed breast), 11954 (injection of the fat into the breast), 15877 (liposuction of the trunk), and 15879 (liposuction of the lower extremities).  Does this seem right?

Answer:
No, none of these are the right codes. The exchange of the tissue expander for a permanent implant requires a capsulotomy so the only code for that procedure is 11970 (not 19340, 19370, 19380). The fat grafting may be separately reported using 20926 which includes the harvest and placement/injection of the fat into the defect. So you’ll use only 11970 and 20926.

*This response is based on the best information available as of 05/11/17.