Contributors: Chasity Speaks and Megan Johnson
In October we raise awareness for Breast Cancer since it is the second most common cancer that women in the United States face according to the CDC. Every year in the United States, we see cases of about 264,000 in women and 2,400 in men. The mortality rate for women is higher at 42,000 and 500 for men just in the U.S. alone. It is vital that we raise awareness for prevention, early detection, and access to treatment.
When a person is diagnosed with breast cancer it is due to the cells in the breast growing out of control. There are different kinds and stages that will determine which breast cells will become cancerous.
When reporting the diagnosis and treatments for a breast cancer patient, we need to understand the anatomy of the breast and the tissue types that are present.
1. Lobules. These are the glands that produce milk
2. Ducts. The Ducts carry the milk to the nipple.
3. Connective tissue. The connective tissue both fibrous and fatty surrounds these areas, holding them together.
The concern with breast cancer and the tissues is that it can spread to other tissue and even the lymph nodes, which is why early detection is so important for early treatment and to increase the chances of survival.
Take Preventative Measures
When a patient reaches a certain age, insurance carriers will cover preventative exams such as mammograms and upon diagnosis, an ultrasound may be needed for follow-up.
First, we will look at the proper code selection for the preventative stage with our Mammogram codes. Currently, the following codes are applicable for Mammography screening:
CPT Coding for Screening Mammography:
● Mammography: Screening 77067, G0279– The screening test is performed on asymptomatic patients as a preventative measure once they reach a certain age or have a family history indicating its need. The use of computer-aided detection (CAD) in these screenings allows an x-ray to be taken of the breast that allows a digital conversion to take place. The radiologist can review the result and then use the CAD Software to highlight areas of abnormalities more clearly. Coverage for these services for Medicare and many payers are indicated as once in your lifetime (if you’re a woman between ages 35-39), once every 12 months (if you’re a woman aged 40 or older), or more than once a year, if medically necessary.
● Mammography: Diagnostic 77065-77066– The diagnostic mammography services are covered by Medicare and many third-party insurance payers if there are signs and symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, with a physician’s interpretation of the results.
These tests also carry a professional and technical portion, so you will want to append either a 26 or a TC modifier as indicated based on your facility.
Additionally, a physician may decide to perform a diagnostic breast ultrasound which utilizes high-frequency sound waves to provide a detailed image of the inside of your breast. What will this accomplish? Since this type of test lets you see deeper structures than a mammogram, it can provide information about small areas within the breast that are difficult to see in detail otherwise. The Codes utilized are:
76641– Ultrasound, breast, unilateral, real-time with image documentation, including axilla when performed; complete
76642– Ultrasound, breast, unilateral, real-time with image documentation, including axilla when performed; limited
The difference between these two codes is the structures that will be used to analyze the breast. In a complete ultrasound, the physician will examine all four quadrants of the breast and the retro areolar region. With a limited exam, they will be looking at one or more of these areas, but it will not be a complete exam as with the 76641 In both codes, the axillary region is viewed or is intended to be viewed. The goal is to view the structures needed and then provide documentation of what they are seeing. The anatomy of the axillary region is often confused for an extremity or musculoskeletal structure due it its proximity to the upper extremity. The breast surgeon may analyze the axilla, but the main portion of the test is looking at the breast tissue, and looking at the axillary region may indicate lymph node involvement.
Diagnosis and Staging
After a diagnosis of breast cancer or for those who are at high risk, an MRI might be indicated for the extent of the disease. MRI detection is more sensitive, especially for women with dense breast tissue. It can even detect if you have invasive breast cancer a lot sooner than if you just get a mammogram. The codes that utilize MRI Guidance or CAD (Computer Aided Detection) are:
77046 Magnetic resonance imaging, breast, without contrast material; unilateral
77048 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; unilateral
In 77048 it may be necessary to view it without contrast and then with contrast to analyze to see any abnormalities. With the CAD images, they can see if there are lesions that enhance to a greater extent than the normal background enhancement. They can also compare to previous studies and see if a biopsy is warranted or a more invasive procedure. This brings us to the next step in the treatment process, the surgical step.
Once a diagnosis is confirmed and treatment is recommended of a surgical nature, the physician will use what he or she has learned in the phase of the image to order the best, most effective treatment for the patient. Working closely with your surgeon to accurately report these codes is vital. Michael J. Cross M.D., F.A.C.S., (Certified by The American Board of Surgery) is a Surgical Breast Oncologist in Northwest Arkansas, and he states:
“Accuracy in coding and the intention of the code is at the top of the list. This requires a collaborative effort between the Doctor and the Coder. A surgeon is familiar with the anatomy of the breast including the axilla. Most of the time it will be a surgeon, who also will want to take their ultrasound to the OR and use it to place wires, to evaluate the location of cancer or use it for axillary evaluation. Ultrasound of the surgical specimen can be used to determine the margins and to remove a specific lymph node in surgery as well as used in the office for diagnostic imaging and confirmation of the location of cancer that has been diagnosed. A coder can help the surgeon include essential information that needs to be present that will lead to a clean code, clean claim, and hopefully a clean reimbursement.”–Dr. Michael J. Cross M.D., F.A.C.S
Dr. Cross is a leading educator of other surgeons and he also noted:
“When I teach other surgeons, they need to know the knobology of the ultrasound machine, anatomy of the breast and axilla, biopsy techniques, and correct knowledge of ultrasound vocabulary. The surgeon needs to know the vocabulary of discussion of what he sees and what is not seen.”-Michael J. Cross M.D., F.A.C.S
Surgical Treatment Challenges
After one has been diagnosed with breast cancer, the next process is weighing the surgical and medical options for treating cancer.
The physician will discuss with the patient the best treatment options depending on the type of breast cancer, the stage, the size, sensitivity to hormones, and if it has metastasized or spread.
Treatment options are considered based on the stage and may consist of surgical options such as excision of a breast lesion, lumpectomy, and mastectomy. The CPT codes reported are:
19120 – Excision of the cyst, fibroadenoma, or another benign or malignant tumor, aberrant breast tissue, duct lesion, nipple, or areolar lesion (except 19300), open, male, or female, 1 or more lesions
19125– Excision of breast lesion identified by the preoperative placement of radiological marker, open; single lesion) – surgery to remove abnormal breast tissue or lumps such as a cyst or tumor. With this procedure, the physician uses radiologic markers to identify breast tissue to be excised for biopsy
19301– Lumpectomy (partial mastectomy) – surgery to remove a single lump or portion of the breast tissue
19302– Lumpectomy with axillary lymphadenectomy- surgery to remove a single lump or portion of the breast tissue and nearby lymph nodes may also be removed. The lymph nodes between the pectoralis major and minor muscles and nodes in the axilla are removed through a separate incision.
19303 Mastectomy, is a simple, complete- surgery to remove the entire breast, or both breasts (double mastectomy)
19305 Radical mastectomy – removal of breasts, underarm lymph nodes, and chest muscles
38500, 38525 – Superficial lymph node biopsy and or excision of the deep axillary lymph nodes.
Lumpectomy is also termed a (partial mastectomy) and is the complete surgical removal of a primary tumor, but not a complete removal of the breast. Types of lumpectomy procedures are excisional biopsy, wide local excision, and re-excision lumpectomy. The key to reporting a lumpectomy procedure is understanding how much is being excised or removed. CPT 19120 and 19301 can often be confused but the key is the intent, the tissue involved, and the diagnosis. Cancer is not always the reason to go right to a 19301. It has to do with what is being excised because with 19301 the surgeon will take a margin or rim of healthy tissue. The intent, of course, is to capture the mass within the breast tissue at the area of concern but may require the removal of additional structures. If the intent is to remove the lump and the lymph nodes between the pectoralis major and the pectoralis minor muscles in addition to the nodes in the axilla this would be a complete axillary lymph excision reported by CPT 19302. In many cases, they may not take the full axillary chain and just remove some of the axillary lymph nodes. Instead of utilizing a modifier, the appropriate step is to utilize additional CPT codes to describe this work. CPT codes 38500 and 38525 describe the extra work of excising the lymph nodes during a partial mastectomy without removing the full chain.
In conjunction with a partial mastectomy in cases where cancer is advanced, radiation therapy after a partial mastectomy may be utilized. Codes are assigned as add-on services with CPT 19301-19302 for the placement of radiotherapy after loading expandable catheters following a partial mastectomy, which will include imaging guidance either on the day of the procedure (19297) or on a separate day (19296). The surgeon will work with the radiation oncologist as the radiation is delivered at a frequency of twice daily for five to seven days depending on the type of cancer.
Mastectomy (simple or complete) involves the complete removal of all breast tissue. Types of mastectomy procedures are total mastectomy, double mastectomy, nipple-sparing mastectomy, and radical mastectomy. In 19303 the complete mastectomy involved the entire breast and not just a limp and surrounding tissue. They can of course spare the nipple by preserving it and later having the area reconstructed. The term radical though with CPT 19305-19307 for instance involved taking margins for removal of surrounding muscle tissue and nearby lymph nodes. What they take will differ and necessitate the various code options, so attention to detail and a clear understanding of anatomy are key when coding these procedures.
Surgical Reconstruction of the Breast
After a patient receives surgical treatment, Breast reconstruction may be needed to restore shape to your post-surgical breast. Reconstruction can be done at the time of a mastectomy or afterward. As mentioned earlier, a breast surgeon can perform a skin-sparing mastectomy to save as much skin as possible for the reconstruction phase.
They can do this in two stages, where they will first place a tissue expander that will be filled with saline at various visits post-mastectomy.
Then as part of the second stage, with hopefully enough healing taking place, they can remove the expander and insert an implant.
During these procedures, there are many ways to reconstruct that involve flaps and grafts, which can be provided by various anatomical sites on the body such as the abdomen, back, thigh, or buttocks.
The challenge with these procedures from a billing standpoint is that many insurances may view them as cosmetic and will not provide coverage under the patient’s policy. Clear documentation showing medical necessity is crucial not only for prior authorization but also to stand up to an appeal if a denial takes place. We will examine the various reconstruction codes used, their purpose, and how to obtain proper reimbursement.
To obtain proper reimbursement you will want to review the Women’s Health and Cancer Rights Act of 1998 (WHCRA) for breast cancer patients. Women’s Health and Cancer Rights Act (WHCRA) | CMS
Under this law, coverage must be provided for:
● All stages of reconstruction of the breast on which the mastectomy has been performed.
● Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
● Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.
This law applies to two different types of coverage:
1. Group health plans (provided by an employer or union).
2. Individual health insurance policies (not based on employment).
We need to first determine what is being ordered, the reason, and what additional procedures are being performed at that time that may be bundled or included in the service. We will review the most common reconstructive procedures along with ancillary services that are separately reportable.
19361 Breast reconstruction; with latissimus dorsi flap
A surgeon will utilize tissue expanders, implants, skin or muscle flaps, and other reconstructive devices to reconstruct a breast after mastectomy. Additional procedures may be needed to achieve the desired size or shape. In 19361 the reconstruction will utilize a latissimus dorsi flap. This involves a transfer of skin and muscle from the patient’s back to their affected breast to correct the defect created by the mastectomy, typically a radical procedure where the cancer was the reason for the mastectomy. It is called a latissimus dorsi flap because they take this muscle and skin from nearby structures. They will then have to rotate the flap under the armpit so that it can cover the mastectomy site. The guidelines do allow for separate reporting of a breast implant or tissue expander with the reconstruction, as necessary.
Keep in mind this is currently an inpatient-only code per the CMS inpatient code list. This will also include CPT codes 19364, 19367, 19368, and 19369.
19380 Revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)
This procedure code is utilized to reconstruct a breast or nipple after a mastectomy has been performed. As indicated in the code description, if performed, it includes tissue expanders, implants, skin or muscle flaps, and other reconstructive devices. There may be ancillary procedures performed and billed to allow for a desired size or shape. It is important that the medical necessity criteria are met for this procedure. It can be considered cosmetic by payors, and they also may have a yearly limit on how many times this procedure can be performed. Be aware of specific plan limitations and that medical necessity is clearly documented.
19318 Breast reduction
CPT Code 19318 is also referred to as a reduction mammoplasty. While this can be done for cosmetic purposes, there are medically necessary reasons to perform this procedure and various policies that need to be consulted for criteria. You will want to make sure that documentation includes all the required information to support medical necessity. Physicians will typically document (breast hypertrophy) or an increase in the volume and weight of breast tissue as it relates to the general body habitus. This condition can affect other body systems such as musculoskeletal, respiratory, and integumentary. When one-sided hypertrophy exists, it may result in symptoms on the other contralateral side where the mastectomy took place. Every patient will vary as to variations in height, weight, and breast size that cause symptoms. The amount of tissue that must be removed to relieve symptoms will vary and depend upon these variations.
A method used in this evaluation is the Schnur sliding scale to consider breast reduction surgery. If the patient’s body surface area and the weight of breast tissue would fall above the 22nd percentile, then they would consider surgery medically necessary. To receive approval from the insurance, they will usually require pre-op photos to confirm this evaluation. Documentation will be key.
19328 Removal of intact breast implant
Last year breast reconstruction codes underwent a major revision and CPT code 19328 was one of them. The reason to perform a breast implant removal for medical necessity is due to infection or an abscess. The physician may state the procedure will be for the “removal of a breast implant with washout.” This code will include the drainage of any associated abscess cavity or infection. As with other areas of CPT, debridement of nonviable tissue associated with the breast implant or soft tissues is not reported separately. In other revised codes for 2021, we see where the removal of the implant would be an integral part of the procedure and not separately billable such as in 19370 or 19371 where part of the intracapsular contents, are removed in a capsulectomy. (Source: CPT Assistant April 2021, Volume 31 Issue 4).
15777 Acellular Dermal Matrix Graft
15777 is an add-on code to correct a soft tissue defect of the trunk or breast. It is important to check individual payor coverage policies for approved products for this type of graft. Just because you have received authorization for CPT 15777, or even if it does not require prior authorization, it will not guarantee payment, as some commercial carriers have coverage criteria and require you to use a product that is approved. Many products are deemed “experimental” or “investigational.”
You will also want to check for and obtain prior authorization for the specific products utilizing HCPCS Level II codes as this will be helpful and appreciated by the facilities as they bill for the product itself.
When billing 15777, you will notice that the MPFS (Medicare Physician Fee Schedule) has an MUE (Medically unlikely edit) of 1, but an MAI (MUE adjudication indicator) of 3. The Medicare physician fee schedule identifies different procedures with indicators to allow for additional units on that claim line. If an indicator of 3 is used, Per CMS, “appealed additional units are considered if there is adequate documentation of medical necessity to support reported units.” Do not let these slip by. They can be appealed and paid.
With a good understanding of the guidelines, disease process, and regulatory guidance from Medicare and other payors, we can be successful in helping our patients obtain these much-needed services. The goal is always early detection but if we understand the correct documentation and communication needed between these different service lines, our patients can get the care they need to improve their quality of life.