Disproportion of reconstructed breast

This code signifies an undesirable size or shape discrepancy of a breast that has undergone reconstructive surgery. This disproportion can manifest as asymmetry between the reconstructed breast and the native breast, or as an unsatisfactory aesthetic outcome of the reconstructed breast itself. It indicates a complication or sequela of the prior reconstructive procedure.

Apply this code when documentation explicitly states a disproportion or asymmetry of a reconstructed breast. This typically occurs during follow-up appointments after breast reconstruction, where the patient or surgeon identifies an unsatisfactory cosmetic result requiring further intervention or monitoring. Supporting documentation includes operative reports of the initial reconstruction, physical exam findings, and patient complaints regarding breast appearance.

• Do not use this code for disproportion of a native breast; this code is specific to reconstructed breasts.
• Consider sequencing this code after a code for the underlying reason for reconstruction (e.g., history of mastectomy for malignancy) if still relevant.
• Ensure documentation clearly distinguishes between a reconstructed breast and a naturally asymmetrical breast.