ICD-10 Diagnostic Coding for Breast Reconstruction

ICD-10 Diagnostic Coding for
Breast Reconstruction
Webinar Hosted by:
December 5, 2013
Presented by:
Kim Pollock, RN, MBA, CPC
Meet Kim Pollock
RN, MBA, CPC
Kim Pollock, RN, MBA, CPC specializes in streamlining the operations of
physician practices. For over fifteen years, Ms. Pollock has helped large
group practices, as well as academic and solo practices, improve
collections and efficiency. She teaches the coding courses for the
American Society of Plastic Surgeons and is a nationally recognized
expert in plastic surgery coding and documentation.
Ms. Pollock is recognized across the country for her understanding of
physician coding and reimbursement– both from a clinical perspective
and from a payor side. She is an expert in analyzing payments and
denials and in reengineering practices for revenue cycle enhancement.
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Webinar Policy
Webinars are the property of
KarenZupko & Associates, Inc. and
are for personal use only. They may
not be rebroadcast, retransmitted,
shared, or disseminated without
permission from KZA.
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Learning Objectives
1. Chart a course for initiating an ICD-10-CM assessment in your practice.
2. Measure the impact of ICD-10-CM on your breast reconstruction
practice by reviewing your current diagnosis coding data.
3. Analyze how current diagnosis coding translates to the new
ICD-10-CM system.
4. Sharpen your understanding of how to use diagnosis codes for common
breast reconstruction procedures including symmetry procedures.
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What’s ICD-10?
• International Classification of Diseases, 10th Revision, Clinical Modification
• We are currently using ICD-9-CM.
• Codes are used to calculate MS-DRG payments.
• Compile statistics
• Already being used in 138 countries for mortality
reporting, 99 countries for morbidity. US implemented
for mortality on 1/1/99.
• Other countries use ICD-10 for reimbursement or case
mix: UK, Denmark, Finland, Iceland, Norway, Sweden,
France, Australia, Belgium, Germany, Canada.
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Why Are We Changing?
• ICD-9 is out of date and running out of space
for new codes.
• ICD-10 is the international standard to report
and monitor disease and mortality – USA
must adopt for reporting and surveillance.
• ICD codes are core elements of many health
information technology systems making the
conversion to ICD-10-CM necessary to fully
realize benefits of HIT adoption.
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October
st
1 ,
2014
Have you started planning
for implementation?
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I’m late!
I’m late!
Source: http://en.wikipedia.org/wiki/File:Down_the_Rabbit_Hole.png
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ICD-10-CM Action Agenda
December 2013
Assign due dates, deliverables
and responsibilities – now!
January 2014
February 2014
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ICDICD-1010-CM Action Agenda
1. Inventory your practice
− Who uses diagnosis codes to
perform their job functions?
− What documents need to be
updated?
− Who will need ICD-10 education
and at what level?
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ICD-10-CM Action Agenda
2. Run an ICD-9-CM frequency report.
10-25 Top Most Used ICD-9-CM Codes
Diagnosis
Diagnosis Description
Volume
V51.0
Encounter for breast recon after mast
237
V45.71
Acquired absence of breast/nipple
202
V10.3
Personal history, breast cancer
177
612.0
Deformity of reconstructed breast
122
174.1
Breast cancer, central portion
52
612.1
Disproportion of reconstructed breast
13
V16.3
Family history, breast cancer
7
V84.01
Genetic suseptibility breast cancer
4
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Not every code
is created equal.
¢
¢
$
$
¢ ¢¢ $
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Initial Steps to Implementation
3. Perform Gap Analysis
− Will current documentation support
ICD-10-CM code assignment?
− Where does documentation
improvement education need to be
focused and who needs it the most?
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ICD-10-CM Action Agenda
3. Gap Analysis: Compare ICD-9-CM to ICD-10-CM
ICD-9-CM
V45.71
Acquired absence of
breast and nipple
ICD-10-CM
Z90.10
Acquired absence of
unspecified breast and nipple
Z90.11
Acquired absence of right
breast and nipple
Z90.12
Acquired absence of left breast
and nipple
Z90.13
Acquired absence of bilateral
breasts and nipples
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ICD-10-CM Action Agenda
4. Try “Bilingual” Coding
ICD-10-CM
ICD-9-CM
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ICD-10-CM Action Agenda
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Source: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8348.pdf
CR 8348 instructs that all ICD-10 LCDs and associated
ICD-10 articles will be published on the Medicare
Coverage Database (MCD) no later than April 10, 2014.
All other LCDs and articles (i.e., those LCDs and articles
that do not contain ICD-10 information, or articles not
attached to an LCD) will be published on the MCD no
later than September 4, 2014.
Source: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8348.pdf
Source: http://www.anthem.com/medicalpolicies/policies/mp_pw_a053315.htm
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Anthem Policy: Breast Reconstruction
Approved ICD-9-CM vs ICD-10-CM Codes
21
Queen Latifah
Bilateral breast reduction
19316-50
or
19316
19316-50
Source: www.flickr.com/photos/gdcgraphics/2914086389/in/set-72157607247444523/
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Anthem Policy: Breast Reduction
Source: http://www.anthem.com/medicalpolicies/policies/mp_pw_a053474.htm
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ICD-9-CM vs ICD-10-CM Codes
Covered Diagnoses
Note: N64.81 excludes ptosis of native breast in relation to reconstructed breast (use N65.1).
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6. Use the
New Claim
Form
January 6, 2014
Payers begin processing
January 6 – March 31
Dual period
April 1
Medicare will reject the old form
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New Form Can
Accept More
Diagnosis Codes!
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ICD-9-CM
vs.
ICD-10-CM
• 3-5 characters in length
• 3-7 characters in length
• 1st digit may be alpha; 2nd5th is numeric
• Character 1 is alpha; characters
2 & 3 are numeric; characters 46 can be either alpha or numeric
• Approximately 14,000 codes
• Approximately 69,000 codes
• Limited space for adding
new codes
• Flexibility for adding new codes
• Lacks detail
• Very specific
ICD-9-CM cont.
vs.
ICD-10-CM cont.
• Lacks laterality
• Has laterality
• Difficult to analyze data due
to non specific codes
• Specificity improves coding
accuracy and richness of data for
analysis
• Codes are non-specific and do
not adequately define
diagnosis needed for medical
research
• Detail improves the accuracy of
data used for medical research
• Does not support
interoperability and not used
by most other countries
• Supports interoperability and the
exchange of health data between
other countries & the U.S.
Code Structure and Format
ICD-9-CM
ICD-10-CM
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Steps to Correct ICD-10-CM Coding
1. Review the “Conventions” and “General Coding Guidelines”
sections of the guidelines.
2. Look up the main term and applicable subterms in the
Alphabetic Index and . Be careful – some entries appear in
the next column or on the next page!
3. Note all parenthetical terms that may help in code selection.
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Steps to Correct ICD-10-CM Coding
4. Look carefully at the instructions:
− “see,” “see also,” and “see category” cross-references
− “with”/“without” notes
− “omit code” notes, “due to” subterms
− Other instructions found in note boxes, such as “code by site”
5. Find the code in the Tabular List and verify accuracy. Do not
code just from Alphabetic List.
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Steps to Correct ICD-10-CM Coding
6. Read all instructional material including:
− “includes” and “excludes” notes
− “use additional code” and “code first underlying disease” instructions
− “code also” – more than one code may be required
− “and” represents and/or
− Fourth-, fifth-, and sixth-digit requirements and seventh-digit extension
requirements
7. Confirm and assign the correct code.
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ICD-10-CM Resources
• The book
• CMS
• Your EHR /practice management • Proprietary mapping tools
information system
Sources: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10
https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1250081&navAction=push
http://www.cpticdpros.com/icd10-coding.html
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GEMS
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Example:
Robust Mapping Software
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ICD-10-CM Coding Conventions
• “Other” codes: use when the information in the
medical record provides detail for which a specific
code does not exist.
• “Unspecified” codes: Use when the information in the
medical record is insufficient to assign a more specific
code.
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ICD-10-CM Coding Conventions
• Certain ICD-10-CM categories have applicable 7th
characters.
− The applicable 7th character is required for all codes within
the category, or as the notes in the Tabular List instruct.
− If a code requires a 7th character and is not 6 characters in
length, a placeholder “x” must be used to fill in the empty
characters.
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7th Character Example
• T85.43-
Leakage of breast prosthesis and implant
• T85.43xA
initial encounter
• T85.43xD
subsequent encounter
• T85.43xS
sequela
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What is a Sequela?
ICD-10-CM Says about Late Effects (Sequela):
• The residual effect (condition produced) after the acute phase of
an illness or injury has terminated. There is no time limit on when
a late effect code can be used.
• Coding of late effects generally requires two codes sequenced in
the following order: The condition or nature of the late effect is
sequenced first. The late effect code is sequenced second.
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What is a Sequela?
ICD-10-CM Says about Late Effects (Sequela):
• Example: A patient returns to see you ten years after breast
reconstruction with a prosthesis and the implant is leaking.
• Codes:
1. N65.0 Deformity of reconstructed breast
2. T85.43xS Leakage of breast prosthesis and implant
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General Coding Guidelines
• Laterality: The final character of the code indicates laterality for
bilateral sites. If no bilateral code is provided and the condition is
bilateral, assign separate codes for both the left and right side.
ICD-10-CM
Z90.10
Acquired absence of unspecified
breast and nipple
Z90.11
Acquired absence of right breast
and nipple
Z90.12
Acquired absence of left breast and
nipple
Z90.13
Acquired absence of bilateral
breasts and nipples
• Unspecified: The medical record is
insufficient to assign a more
specific code.
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Breast Reconstruction
Specific ICD-10-CM Coding
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Using a Breast Cancer
Diagnosis Code
• What disease are you treating?
• Use breast cancer diagnosis code for office visits premastectomy/resection.
• May also use as a secondary diagnosis for immediate
reconstruction at same operative session as
mastectomy.
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Breast Cancer Diagnosis Codes
Need to know:
• Area on breast – nipple/areola, central, upper-inner
quadrant, lower-inner quadrant, upper-outer quadrant,
lower-outer quadrant, axillary tail, overlapping sites,
unspecified site
• Sex of patient – female (ICD-9-CM = 174.x, ICD-10-CM = C50.1), male (ICD-9-CM = 175.x, ICD-10-CM = C50.-2)
• Laterality – right, left, unspecified
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Breast Cancer Diagnosis Codes
ICD-9-CM
ICD-10-CM
174.0 Malignant neoplasm
of female breast,
nipple and areola
C50.011 Malignant neoplasm of nipple
and areola, right female breast
C50.012 Malignant neoplasm of nipple
and areola, left female breast
C50.019 Malignant neoplasm of nipple
and areola, unspecified female
breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.1 Malignant
neoplasm of
female breast,
central portion
ICD-10-CM
C50.111
Malignant neoplasm of central
portion of right female breast
C50.112
Malignant neoplasm of central
portion of left female breast
C50.119
Malignant neoplasm of central
portion of unspecified female
breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.2
Malignant neoplasm
of female breast,
upper-inner
quadrant
ICD-10-CM
C50.211
Malignant neoplasm of
upper-inner quadrant of
right female breast
C50.212
Malignant neoplasm of
upper-inner quadrant of left
female breast
C50.219
Malignant neoplasm of
upper-inner quadrant of
unspecified female breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.3
ICD-10-CM
Malignant neoplasm C50.311
of female breast,
lower-inner quadrant
C50.312
C50.319
Malignant neoplasm of
lower-inner quadrant of
right female breast
Malignant neoplasm of
lower-inner quadrant of left
female breast
Malignant neoplasm of
lower-inner quadrant of
unspecified female breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.4
ICD-10-CM
C50.411 Malignant neoplasm of
Malignant neoplasm
of female breast,
upper-outer quadrant of
right female breast
upper-outer quadrant
C50.412 Malignant neoplasm of
upper-outer quadrant of left
female breast
C50.419 Malignant neoplasm of
upper-outer quadrant of
unspecified female breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.5
Malignant neoplasm
of female breast,
lower-outer
quadrant
ICD-10-CM
C50.511
Malignant neoplasm of
lower-outer quadrant of
right female breast
C50.512
Malignant neoplasm of
lower-outer quadrant of left
female breast
C50.519
Malignant neoplasm of
lower-outer quadrant of
unspecified female breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.6
Malignant neoplasm
of female breast,
axillary tail
ICD-10-CM
C50.611
Malignant neoplasm of axillary
tail of right female breast
C50.612
Malignant neoplasm of axillary
tail of left female breast
C50.619
Malignant neoplasm of axillary
tail of unspecified female
breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.8 Other specified sites of female
breast
Ectopic sites
Inner breast
Lower breast
Midline of breast
Outer breast
Upper breast
Malignant neoplasm of contiguous
or overlapping sites of breast
whose point of origin cannot be
determined
ICD-10-CM
C50.811
Malignant neoplasm of
overlapping sites of right
female breast
C50.812
Malignant neoplasm of
overlapping sites of left
female breast
C50.819
Malignant neoplasm of
overlapping sites of
unspecified female breast
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Breast Cancer Diagnosis Codes
ICD-9-CM
174.9
ICD-10-CM
Malignant neoplasm C50.911 Malignant neoplasm of
unspecified site of right
of female breast,
female breast
unspecified
C50.912 Malignant neoplasm of
unspecified site of left female
breast
C50.919 Malignant neoplasm of
unspecified site of unspecified
female breast
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Post-Mastectomy
Diagnosis Codes
ICD-9-CM
V45.71
Acquired absence of
breast and nipple
ICD-10-CM
Z90.10
Acquired absence of
unspecified breast and nipple
Z90.11
Acquired absence of right
breast and nipple
Z90.12
Acquired absence of left
breast and nipple
Z90.13
Acquired absence of bilateral
breasts and nipples
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Post-Mastectomy
Diagnosis Codes
ICD-9-CM
V10.3
Personal history of
malignant neoplasm,
breast
ICD-10-CM
Z85.3
Personal history of
malignant neoplasm
of breast
• Use when you are not treating the cancer
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Other Diagnosis Codes
ICD-9-CM
V84.01 Genetic susceptibility to Z15.01
malignant neoplasm of
breast
ICD-10-CM
Genetic susceptibility
to malignant neoplasm
of breast
• Code first, if applicable, any current malignant neoplasm (C00C75, C81-C96).
• Use additional code, if applicable, for any personal history of
malignant neoplasm (Z85-).
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Other Diagnosis Codes
ICD-9-CM Diagnosis Description
V51.0
•
•
Aftercare involving the use
of plastic surgery,
Plastic surgery following
healed injury or operation,
Encounter for breast
reconstruction after
mastectomy
ICD-10-CM
Diagnosis Description
Z42.1
Encounter for plastic and
reconstructive surgery following
medical procedure or healed
injury,
Encounter for breast
reconstruction following
mastectomy
Codes is intended for use to indicate a reason for care. It may be used for patients who have already
been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to
consolidate the treatment, or to deal with a residual state.
Examples include: 1) tissue expander exchange to permanent implant, 2) revision of reconstructed
breast, 3) nipple/areola reconstruction, 4) post-op reconstruction visits. Do not use for immediate
reconstruction procedures.
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Angelina Jolie
Stage 1: Immediate bilateral breast
reconstruction with tissue expanders
after bilateral prophylactic
mastectomies.
CPT Codes/Modifiers – “Bundled Format”
19357-50
Breast reconstruction, immediate
or delayed, with tissue expander,
including subsequent expansion
Source: www.justjared.com/photo-gallery/2634193/angelinajolie-twins-shopping-07/
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Angelina Jolie
ICD-9-CM
ICD-10-CM
V45.71
Acquired absence Z90.13
of breast and
nipple
Acquired absence of
bilateral breasts and
nipples
V84.01
Genetic
susceptibility to
malignant
neoplasm of
breast
Genetic
susceptibility to
malignant neoplasm
of breast
Source: www.justjared.com/photo-gallery/2634193/angelinajolie-twins-shopping-07/
Z15.01
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Claim Format for Use of Modifier 50
Payor Preference
Claim Form Format
“Bundled” Format
Line-Item Format
Placement of Code and
Modifier
One line
19357-50
Two lines
19357
19357-50
Number of Units
1 (though some payors
may want 2)
1
Billed Fee
Double your unilateral fee
Use your unilateral fee
Expected Payment
150% of allowable
100% for first code
50% for second code
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Angelina Jolie
What if stage 1 was: Bilateral immediate breast reconstruction
with tissue expanders with placement of biologic material
CPT Codes/Modifiers “Bundled” Format
19357-50
Breast reconstruction, immediate or
delayed, with tissue expander, including
subsequent expansion
+15777-50 Implantation of biologic implant (eg,
acellular dermal matrix) for soft tissue
reinforcement (eg, breast, trunk) (List
separately in addition to code for primary
procedure)
Source: www.justjared.com/photo-gallery/2634193/angelinajolie-twins-shopping-07/
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Angelina Jolie
CPT Codes/Modifiers Line-Item Format
19357
Breast reconstruction, immediate or delayed,
with tissue expander, including subsequent
expansion
19357-50
(as above)
+15777
Implantation of biologic implant (eg, acellular
dermal matrix) for soft tissue reinforcement
(eg, breast, trunk) (List separately in addition
to code for primary procedure)
+15777-50
(as above)
Source: www.justjared.com/photo-gallery/2634193/angelinajolie-twins-shopping-07/
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Christina Applegate
Bilateral mastectomy for early
stage breast cancer in one breast
and a prophylactic mastectomy
due to being a carrier of the
BRCA1 gene mutation with
immediate breast reconstruction.
Source: www.flickr.com/photos/lge/7451347634/
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Reconstruction Diagnosis Codes
ICD-10-CM
Z90.13
Acquired absence of bilateral breasts and
nipples
Z85.3
Personal history of malignant neoplasm of
breast
(note no laterality required)
Z15.01
Genetic susceptibility to malignant
neoplasm of breast
(note no laterality required)
Source: www.flickr.com/photos/lge/7451347634/
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Giuliana Rancic
Assume immediate bilateral breast reconstruction
with placement of permanent prostheses after
mastectomies for cancer.
CPT
19340-50
Immediate
insertion of
breast
prosthesis
following
mastopexy,
mastectomy
or in
reconstruction
ICD-9-CM
ICD-10-CM
V45.71
Acquired
absence of
breast and
nipple
Z90.13
Acquired absence
of bilateral
breasts and
nipples
V10.3
Personal
history of
malignant
neoplasm,
breast
Z85.3
Personal history of
malignant
neoplasm of
breast
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Other Commonly Used Codes
ICD-9-CM Description
ICD-10-CM
612.0
Deformity of reconstructed breast, Contour
irregularity in reconstructed breast, Excess
tissue in reconstructed breast, Misshapen
reconstructed breast
N65.0
612.1
Disproportion of reconstructed breast, Breast
asymmetry between native breast and
reconstructed breast, Disproportion between
native breast and reconstructed breast
N65.1
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Sharon Osbourne
Assume bilateral revision of reconstructed breasts
(19380-50) and bilateral nipple/areola reconstruction
(19350-50).
ICD-9-CM Description
ICD-10-CM
V50.1
Encounter for plastic and reconstructive surgery
following mastectomy
V45.71
Acquired absence of breast and nipple
612.0
Deformity of reconstructed breast, Contour
irregularity in reconstructed breast, Excess tissue in
reconstructed breast, Misshapen reconstructed breast
N65.0
V10.3
Personal history malignant neoplasm, breast
Z85.3
Source: commons.wikimeida.org
Z42.1
Z90.13 bilateral
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Jewel
Assume right immediate breast reconstruction
and placement of permanent prosthesis after
mastectomy for cancer and left breast
mastopexy for symmetry.
Codes
Right
Left
CPT
19340
19316
ICD-9-CM
V45.71
V10.3
V10.3
612.1
ICD-10-CM
Z90.11 right
Z85.3
Z85.3
N65.1
Source: www.flickr.com/photos/99527366@N00/4008178941
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Be Prepared for ICD-10-CM:
Don’t Pull a Scarlett
I’ll think about it
tomorrow.
69
Source: www.fotopedia.com/wiki/Vivien_Leigh#!/items/flickr-3410279330
Questions?
70
Thank You!
Kim Pollock, RN, MBA, CPC
www.karenzupko.com
info@karenzupko.com
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