Tissue-Expander Procedure Coding

Vol. 18 • Issue 24 • Page 9
Coding Corner

Pre- and postoperative diagnosis: Left peri-implant infection of the left breast

Procedure: Incision, drainage and removal of tissue expander of the left breast

Indications: The patient is a 38-year-old female who has undergone a left reconstruction with a tissue expander. She has a peri-implant infection and the expander requires removal.

Procedure: The patient was taken to the operating room, induced with general anesthesia in the supine position. The left chest was prepped and draped aseptically in the usual sterile fashion. The previous incision was opened. The tissue expander was removed. Copious purulence was suctioned from the wound. The wound was then Pulsavac’d with 2 liters of antibiotic ortho saline solution. A hemovac drain was placed and secured to the skin

with 3-0 silk suture.

The wounds were closed by approximating the subcutaneous tissues and dermis with 3-0 PDS interrupted in an inverted fashion. Skin was closed with 5-0 Prolene in a running fashion. The patient tolerated the procedure well. The patient was extubated and taken to recovery room in stable condition.

ICD-9-CM Diagnosis Codes

996.69 Infection and inflammatory reaction due to other internal prosthetic device/implant/graft

E879.8 Other procedure, with abnormal reaction/late complication-no misadventure during procedure

ICD-9-CM Procedure Codes

86.04 Incision and drainage of skin and subcutaneous tissue

85.96 Removal of breast tissue expander

CPT Procedure Codes

10180 Incision and drainage, complex, postoperative wound infection

11971LT Removal of tissue expander(s) without insertion of prosthesis

Coding Rationale

Per the physician documentation, the patient had an infection of a breast wound where a tissue expander had been inserted. This is an infection due to a reaction of an internal device.

For the ICD-9 code assignment, coders should check in the index under “infection due to the presence of an implant, postoperative wound” and will arrive at code 996.69. Assignment of code E879.8 indicates this was a late reaction/complication that occurred.

The physician performed an incision and drainage of the postoperative wound with removal of the tissue expander.

CPT code 10180 describes the incision and drainage of the postoperative wound. In the documentation, the physician stated, “Copious purulence was suctioned from the wound,” which reflects the incision with drainage. He further documents the tissue expander was removed from this wound without the insertion of a permanent prosthesis. Therefore, the first stop in the index will be to find the entry for the removal of the tissue expander. So, you will look up the word Removal in the index. Among the many choices under this term, you will find Tissue Expanders and the indented term of Skin . 11971. A review of this in the integumentary subsection of the surgical section of the CPT manual shows this is correct.

Hospital coders should be sure to add modifier “LT” to the code to show the procedure was performed on the left breast.

11971LT Removal of tissue expander(s) without insertion of prosthesis, Left side

The next stop in the Index will be Incision and Drainage and then Wound Infection followed by Skin . 10180. A read through this code in the general surgery section of the CPT code manual shows it is the correct choice for the procedure performed.

10180 Incision and drainage, complex, postoperative wound infection

Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.

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