Encounter for breast reconstruction following mastectomy

This code signifies a patient visit specifically for the purpose of undergoing or planning breast reconstruction surgery after a mastectomy. It covers the medical management and surgical procedures involved in restoring breast form following the removal of breast tissue due to cancer or other conditions.

Apply this code when a patient presents for an initial consultation, pre-operative workup, the reconstruction surgery itself, or post-operative care directly related to breast reconstruction following a mastectomy. This includes both immediate and delayed reconstruction procedures.

• Do not use this code for follow-up care of complications or unsatisfactory results of the reconstruction; refer to N65.1- for those scenarios.
• Always code the underlying reason for the mastectomy (e.g., breast cancer history) as a secondary diagnosis, if applicable.
• Ensure documentation clearly states the purpose of the encounter is for breast reconstruction following a mastectomy.