Question

A patient presents for reduction of her left breast due to atrophy of the breast. After being prepped and draped, the surgeon makes a circular incision above the nipple to indicate where the nipple is to be relocated. Another incision is made around the nipple, and then two more incisions are made from the circular cut above the nipple to fold beneath the breast, which creates a keyhole shaped skin and breast incision. Skin wedges and tissue are removed until the surgeon is satisfied with the size. Electrocautery was performed on bleeding vessels and the nipple was elevated to its new position and the nipple pedicle was sutured with layered closure. The last incision was repaired with a layered closure as well. What is the correct CPT code to report for this example?

Answer 1

The correct CPT code to report for the example given is 19318, which represents a reduction mammoplasty.

Step-by-step explanation:

The correct CPT code to report for the example given is 19318. This code represents a reduction mammoplasty, which is the surgical procedure described in the question. The code 19318 includes the removal of breast tissue, elevation of the nipple, and closure of the incisions. It is important to note that this is just one possible CPT code option, and the final code selection should be based on the specific documentation and guidelines provided by the American Medical Association (AMA) and the payer.