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Pre-op Diagnosis:
History of left breast cancer [Z85.3]
Acquired absence of breast and absent nipple, left [Z90.12]
Breast asymmetry between native breast and reconstructed breast [N65.1]
*
Post-op Diagnosis:
same
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Procedure:
*
BREAST RECONSTRUCTION UNILATERAL
BREAST IMPLANT AND CAPSULE REMOVAL
MAMMOPLASTY AUGMENTATION
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*
presents for delayed left breast reconstruction after mastectomy. She also presents for right breast implant removal and replacement.
Procedure:
Attention was first turned to the right breast. Incision was made through her prior augmentation scar. I dissected down through her breast tissue until identified a subglandular breast implant capsule. I circumferentially dissected around the capsule using electrocautery and a lighted breast retractor. I was able to completely dissect around the capsule and remove the capsule and the implant en bloc from the patient. On the back table I opened the capsule to identify ruptured silicone implants. The capsule was thickened and calcified in multiple places. The capsule was contracted and had taken on a football like elliptical shape. I then used a saline sizer measuring 380 to 450 cc in the subglandular pocket. I tried a variety of fill volumes from 400-450 to fill the pocket. Patient did remain ptotic but had an improvement in her overall breast appearance. I then removed the sizer irrigated the pocket with an antibiotic irrigation. Hemostasis was achieved using electrocautery. A 15 French round JP drain was placed in the pocket. I changed my gloves and placed a smooth round high profile saline implant 380 to 450 mL. It was filled with 450 mL’s of sterile saline. The capsule was then closed with 3-0 interrupted Vicryl suture. The skin was closed with interrupted 3-0 Vicryl dermal sutures and running 4 oh strata fix Monocryl.
*
I then incised the left mastectomy scar. I raised subcutaneous flaps to re-create the mastectomy defect. Care was taken not to ever dissect the pocket inferiorly or laterally. *On a sterile back table, a piece of 16 x 20 cm fenestrated thick alloderm was fenestrated and wrapped around a 475 cc high profile tissue expander. *The suture tabs were brought through the fenestrations and secured to the alloderm using 2-0 vicryl sutures. *Additional sutures were used to close the sides of the alloderm around the expander after a little trimming. **Then the wrapped expander was placed in the left breast defect and secured with 2-0 vicryl interrupted sutures to the pectoralis muscle and rectus fascia. *It was oriented to that the base of the expander lay along the IMF with midline centralized. *A tail of alloderm was secured over the superolateral pectoralis muscle headed toward the axillae. A 15 French JP drain was placed under the skin extending laterally superiorly medially and then inferiorly along the pocket. * It was secured using 4-0 nylon.. **Again, antibiotic irrigation was used. Hemostasis was achieved. The skin was closed in layers with 3-0 Vicryl in the dermis and 4-0 Monocryl subcuticular sutures. Next, a similar procedure was performed on the patient’s right side. Dermabond prineo*was placed. No on table expansion was performed today to avoid tension of the skin flaps. A surgical bra was placed. The patient was awoken from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire*case.
*
*
*
Post-op Diagnosis: SAME
*
CPT Code: Procedure: DIAGNOSTIC EXCISION LEFT BREAST MASS
*PR EXCISE BREAST CYST
*
ICD-10 : Post-Op Diagnosis Codes:
* Breast mass in female [N63.0]
*
Specimens:
ID Type Source Tests Collected by Time
A : palpable mass left breast Breast Breast, Left SURGICAL PATHOLOGY TISSUE EXAM
*
Findings: dense inframammary ridge bilaterally, more pronounced left lower inner parasternal breast margin with ill-defined mass effect. A curved incision was made more centrally with a thick flap created to the area of interest which is generously excised using Harmonic Focus to avoid cautery with her pacemaker in place. At conclusion there is a deliberate flattening of the area without marked contour loss and incision is closed in layers. I did not place a clip.
Indications: She has a prominent inframammary ridge, more so on the left with a slight swelling in the left lower inner quadrant adjacent to the sternum. Imaging discloses no pathology. I performed a needle biopsy and that was nondescript tissue and I would have expected fat necrosis. As an alternative to continued monitoring, she and I decided to pursue a diagnostic excision both to remove the mass but also to assure absence of a proliferative disorder.
*
Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia with IV antibiotic. The left breast is prepped with chlorhexidine and draped after 3 minutes. A curved incision is made about 3 fingerbreadths from the lower inner quadrant breast margin, scalpel enters the subcutaneous adipose tissue and I now used Harmonic Focus with a thick 6 mm flap dissected to the medial most margin, and then circumferentially until amputated. I take a small volume more inferiorly to result in a smooth transition and deliberate flattening (the mound has been removed). I used 4-0 Vicryl suture and create a lateral subcutaneous flap and attached superficial aspect of this carried medially to the underside of the medialmost flap. A few more simple interrupted subcutaneous sutures were placed and then the skin closed with subcuticular technique. A Steri-Strip was used as a dressing, she tolerated a Steri-Strip before but otherwise is intolerant of other adhesives. She is now awakened and extubated, transported to PACU.
*
Imagine, if you will, a provider states the patient has a lump/mass/cyst/lesion/whatever in the right/left breast, and the aforementioned whatever is, of course, in the 3-, 6-, 9-, or 12-o’clock position.
(READ: Right ON the dang quadrant lines. 😡 )
Can you code the quadrant (and, if so, how do you choose) or can you only code laterality?
Thanx!
Indications for Surgery: 13 weeks status post replacement of bilateral breast implants with revision to prepectoral pocket. She developed a right breast incision dehiscence with cellulitis postoperatively. Her cellulitis was easily controlled, and she has been maintained on oral antibiotics prophylactically. She presents now for implant removal, washout, implant replacement and scar revision. She is aware that she will run increased risk of future infection. *Risks will also include hematoma, seroma, further wound healing issues, scarring, asymmetry, implant loss and need for further surgery.*and I reviewed the*nature, purpose, benefits, usual and most frequent risks of, and alternatives to, the operation or procedure. **The patient had an opportunity to ask questions, and those questions were*answered. Informed consent was then obtained.
*
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Operative Procedure: I began by injecting 30 cc of 0.25% marcaine with Epinephrine into the planned area of incision. On the right I excised a 7 cm long ellipse to completely remove the skin around the dehisced incision. This allowed me to come back to healthy bleeding skin edges. The patient’s intact saline implant was then ruptured and removed. The pocket was inspected and there was no purulent material identified. In fact there was no fluid seen within the pocket at all. The pocket was then copiously irrigated with 3 L of normal saline using a Pulsavac. Antibiotic irrigation was used with 500 cc NS and 1 gram ancef, 80 milligrams gentamycin, and 50,000 units of bacitracin. Following this my gloves were changed. A Mentor smooth round moderate plus profile saline implant style 2000 was then placed. It was expanded to 1100 cc using sterile saline. The implant capsule was then closed using 3-0 Vicryl suture. The skin was closed in layers using 3-0 Vicryl in the dermis and 4-0 Monocryl running subcuticular suture. Dermabond prineo was placed. A surgical bra was placed. The patient was awoken from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire case.
*
thank you
Surgery: Excision of hidradenitis, reconstruction of synmastia with complex closure
Hidradenitis was in the intermammary space (cleavage area of breasts).
It was excision of that, and also reconstruction of synmastia, not just regular closure of excision site — so more complicated.
I was thinking: 11451/19380
Can someone suggest other codes or does that sound about right?? Help anyone please