Breast Procedure Coding in CPT - Reconstruction
Instructor
Beth Martilik, MA, RHIA, CDIP, CCSDescription
Breast Reconstruction Coding in CPT is an online, self-paced course for outpatient and professional fee coders who work with implant-based and flap-based breast reconstruction procedures. This module explains how CPT defines the primary reconstruction techniques, the distinctions between implant and autologous flap options, and how to interpret operative details to assign the correct codes. Coders will also review common adjunct procedures performed during reconstruction or revision, gaining clarity on when these services may be separately reported. The course includes 1 AHIMA CEU and supports more accurate, consistent coding across the full range of breast reconstruction procedures.
Included Lessons:
- Breast Anatomy
- Reconstruction Procedures
- NCCI Policy Manual
- CPT Book Coding Guidelines For Breast Reconstruction
- Coding For Breast Reconstruction Procedures
CEUs available for the following credentials:
AHIMA
CCA, CCS, CCS-P, RHIT, RHIA, CDIP, CHDA, CHPS
Key Takeaways
- Understanding Breast Reconstruction Procedures: Comprehensive knowledge of various breast reconstruction methods such as implants and flap grafts.
- Proficiency in Coding Techniques: Mastery of specific coding conventions and guidelines necessary for accurately documenting breast reconstruction procedures and revisions.
- Insight into Reconstruction Revision Procedures: Detailed understanding of additional procedures that might be carried out as part of reconstruction revision and how they integrate into the overall coding process.
- Adherence to Industry Standards: Development of a strong foundation in current industry standards, ensuring that coding practices align with the latest regulations and ethical considerations in medical coding.
- Hands-On Experience: Practical exposure and application of coding knowledge through examples, case studies, or practice sessions to solidify learning and enhance real-world applicability.
- Enhanced Accuracy and Precision: Skills to improve the accuracy and specificity of coding, minimizing errors and enhancing the reliability of coded data for clinical and billing purposes.
- Continuous Learning and Adaptability: Insights into staying updated with evolving coding guidelines and practices, fostering an ability to adapt to changes in the medical coding landscape.
Benefits of Taking this Course
- Specialized Breast Reconstruction Expertise
- Mastery in Reconstruction Coding
- In-depth Flap Graft Knowledge
- Implant Procedure Coding Skills
- Revision Procedure Familiarity
FAQs
What will I learn about CPT coding for breast reconstruction procedures?
This course explains how to accurately assign CPT codes for common breast reconstruction techniques, including tissue expanders, implant placement, autologous flap procedures, and revision surgeries. You’ll learn how surgical intent, timing, laterality, and the type of reconstruction performed influence code selection. By the end, you’ll understand how to read the operative note and confidently translate reconstruction terminology into correct CPT coding.
How does the course help coders understand the differences between implant-based and autologous reconstruction for accurate code assignment?
The course breaks down how each reconstruction approach is performed and how CPT guidelines differentiate between implant placement, expander insertion, DIEP flaps, TRAM flaps, and other autologous techniques. You’ll review documentation examples that show how anatomical detail, flap type, and surgical steps impact code selection, helping you avoid common errors when coding complex reconstruction cases.
Will this course improve my ability to identify documentation elements needed to code reconstruction stages, revisions, and related procedures?
Yes. The course highlights the key documentation coders must locate, such as the stage of reconstruction, type of device or flap used, removal or exchange of implants, and any concurrent procedures like capsulotomy or fat grafting. You’ll learn how to interpret provider terminology and determine when additional services are separately reportable or bundled, supporting accurate and compliant CPT reporting.
About Our Medical Coding Courses
HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a flexible, online education platform designed for today’s coders. With a growing catalog of AHIMA and AAPC-approved coding courses, HIAlearn supports both beginners and experienced coders looking to build confidence, accuracy, and CEU credits.
Courses are available across various coding types including CPT, E/M, ICD-10-CM, and ICD-10-PCS, and are designed for multiple specialties including inpatient, outpatient, profee, and CDI.
To stay up to date, coders can explore our Coding Updates hub for the latest ICD-10-CM, ICD-10-PCS, CPT, and IPPS changes. HIAlearn also supports organizations with group discounts and scalable team access, promoting accuracy, compliance, and continuous professional development across departments.
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