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Reposition Breast, Bilateral to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | S Reposition |
| Body Part | V Breast, Bilateral |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Moving to its normal location, or other suitable location, all or a portion of a body part
Procedure Overview
Reposition procedures move skin or breast tissue to a different location while leaving it attached to its original blood and nerve supply, unlike a graft or implant that is placed anew. A well-known example is breast reduction or mastopexy, where breast tissue and the nipple-areolar complex are relocated to a higher, more natural position on the chest wall to correct sagging or asymmetry.
These procedures are performed for both functional and aesthetic reasons: correcting a displaced nipple after trauma, repositioning breast tissue during reduction surgery to relieve back and neck strain from excess weight, or moving misplaced skin folds. The tissue itself is not removed from the body or replaced with something new; it is simply relocated to where it functions or appears more normally.
Because the tissue keeps its own blood supply during relocation, these procedures generally carry a lower risk of tissue death compared to a free graft, and healing tends to be more predictable.
Anatomy & Axis Detail
Breast, Bilateral
Bilateral breast repositioning is reported when both breasts are moved to new positions in the same operative episode, most typically during symmetrizing mastopexy for ptosis affecting both sides or as a coordinated step in staged bilateral reconstruction. Operating on both breasts together allows the surgeon to match projection, nipple height, and inframammary fold position between sides, which is often the primary goal driving the bilateral approach rather than treating each breast as an isolated problem. As with unilateral procedures, this code applies only when tissue is relocated rather than excised; concurrent reduction or augmentation performed alongside the lift is captured with additional root operations. Because symmetry is the clinical objective, documentation typically includes measurements or landmarks used to match the two sides rather than treating them as independent procedures.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Coding & Documentation
The operative note needs to describe the tissue being moved and its new anatomic location, distinguishing a true repositioning of existing tissue from a repair that simply closes a wound in place. Coders should confirm that the tissue retained its original attachments and blood supply during the move, since a flap that is completely detached and reattached to a new site with vessel reconnection may be coded differently.
A common error is defaulting to Repair for a breast reduction or mastopexy, when the primary intent of relocating the nipple-areolar complex or breast mound is more accurately captured as Reposition. Coders should also watch for cases where excess skin or tissue is excised as part of the same operation, which requires an additional Excision code alongside Reposition, since removing tissue and repositioning tissue are distinct root operations performed in the same encounter.