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Revision of a reconstructed breast involves surgical procedures aimed at correcting or enhancing the aesthetic appearance of a breast that has previously undergone reconstruction. This type of surgery is often necessary to achieve the desired final result, whether the initial reconstruction was performed using autologous tissue (flaps) or implants. The primary goals of revision surgery include correcting issues related to size, shape, and position of the breast, as well as addressing complications such as infection, necrosis, or capsular contracture. In cases of autologous tissue reconstruction, common reasons for revision include correcting fullness of the flap, contour irregularities, or asymmetry between the breasts. The specific approach to revision surgery is tailored to the individual patient, taking into account the type of reconstruction that was initially performed, the specific aesthetic corrections required, and any current symptoms or complications. Surgical incisions are typically made over existing scars or in the natural crease of the breast to minimize visible scarring. For implant-based reconstructions, the procedure may involve exposing the capsule surrounding the implant, which can be revised by removing excess scar tissue or calcifications, releasing any adhesions, and addressing skin or scar issues. Additionally, the implant may be repositioned or replaced with a different size, shape, or type, which would be reported separately. In the case of flap revisions, the surgeon may excise excess flap tissue, perform liposuction to reduce fullness, re-advance or reset the flap's position, or use grafts from other donor sites to reshape the flap. The introduction of additional autologous fat may also be performed to enhance volume or correct contouring issues. After the breast mound has been reshaped and contoured to the desired aesthetic, drains may be placed as necessary, and the skin is meticulously closed in layers to promote optimal healing.
© Copyright 2025 Coding Ahead. All rights reserved.
The revision of a reconstructed breast is indicated for various reasons, primarily aimed at correcting aesthetic or functional issues that may arise after the initial reconstruction. The following conditions may warrant this procedure:
The procedure for revising a reconstructed breast involves several detailed steps, which may vary based on the specific issues being addressed and the type of reconstruction previously performed. The following procedural steps outline the typical approach:
Post-procedure care following breast revision surgery is crucial for recovery and optimal outcomes. Patients are typically monitored for any immediate complications and provided with instructions for care at home. This may include managing drains if placed, monitoring for signs of infection, and following specific guidelines for activity restrictions. Patients are advised to avoid strenuous activities and heavy lifting during the initial recovery phase. Follow-up appointments are essential to assess healing, remove any drains, and evaluate the aesthetic results of the surgery. The expected recovery time may vary based on the extent of the procedure and individual healing responses, but patients should be prepared for a gradual return to normal activities.
| Short Descr | REVJ RECONSTRUCTED BREAST | Medium Descr | REVISION OF RECONSTRUCTED BREAST | Long Descr | Revision of reconstructed breast (eg, 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) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1A - Major procedure - breast | MUE | 1 | CCS Clinical Classification | 175 - Other OR therapeutic procedures on skin and breast |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GA | Waiver of liability statement issued as required by payer policy, individual case | GJ | "opt out" physician or practitioner emergency or urgent service | GZ | Item or service expected to be denied as not reasonable and necessary | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2021-01-01 | Changed | Code changed. |
| Pre-1990 | Added | Code added. |
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