Deformity of reconstructed breast

This code describes an abnormal shape or structural deviation of a breast that has undergone surgical reconstruction. This deformity can arise from various factors post-reconstruction, such as implant malposition, capsular contracture, or issues with autologous tissue flaps. It signifies a complication or unsatisfactory outcome of a prior breast reconstruction procedure.

Use this code when documentation clearly indicates a patient presents with a visible or palpable deformity of a surgically reconstructed breast. This typically applies to follow-up encounters after a mastectomy and subsequent reconstruction, where the patient or physician identifies an aesthetic or structural issue with the reconstructed breast. Supporting documentation would include physician notes detailing the specific deformity and its relation to the prior reconstruction.

• Always sequence this code after the primary reason for the original breast reconstruction (e.g., history of mastectomy for malignancy).
• Do not use this code for deformities of a natural, un-reconstructed breast; use codes from the 611 series for those conditions.
• Specify the type of reconstruction (e.g., implant, autologous tissue) if known, as this may influence further diagnostic or procedural coding.