Tissue Expander Exchange with Revision of Breast Reconstruction

Question:
I did a tissue expander exchange to permanent prosthesis on a patient and she needed a little bit of fat and excess tissue removed at the same time. I billed 11970 (tissue expander exchange), 19370 (for the capsulotomy) and 19380 (revision of breast reconstruction) but the insurance company wouldn’t pay for 19370 or 19380. I wrote an appeal letter complaining and asked for a re-review. I just got notice that the original denials were upheld. Is the insurance company wrong or did I code it incorrectly?

Answer:

It is difficult to make a determination without seeing the actual operative note. But in general, the capsulotomy (19370) is included in the exchange code, 11970, and not separately reported.

Also, 19380 is intended to be used for revision of a previously reconstructed breast. The breast is not considered to be finally reconstructed at the time of the exchange. It is only after the breast has undergone complete reconstruction than we can use 19380.

So it sounds like the insurance company was correct to pay only 11970.