Do I have the right codes: 19303-50
or am I missing something??
PREOPERATIVE DIAGNOSIS:
Left breast carcinoma, upper outer quadrant with bilateral subglandular
implants.
POSTOPERATIVE DIAGNOSIS:
Left breast carcinoma, upper outer quadrant with bilateral subglandular
implants.
PROCEDURE:
1. Right simple mastectomy and removal of implant.
2. Left simple mastectomy with removal of implant and removal of axillary tail.
This patient had prior lymph node dissection. There was very little to no
tissue in the axilla as this had been stripped in the prior axillary node
dissection.
ASSISTANT:
xxxxxx
ANESTHESIA:
General.
ANESTHESIOLOGIST:
Dr. English.
ESTIMATED BLOOD LOSS:
Minimal.
PROCEDURE IN DETAIL:
The patient was placed on the operating table in supine position. After
administering general anesthesia, the patient’s upper chest, arms, and down to
the elbow were prepped along with the neck, prepped and draped in usual
fashion. Time-out was performed. Attention was turned to the right side,
which was benign. The oblique elliptical incision was made, sharply carried
down to subcutaneous tissue with the cautery. Then, utilizing a Gorney
scissors, skin flaps were created appropriate thickness, approximately 8-7 inch
and slightly less superiorly to the clavicle, medially to the sternum, inferiorly to the rectus, laterally to the latissimus dorsi. The breast tissue
was reflected from medial to lateral along with the implant, which was
subglandular, muscle was left intact. After this was removed, the area was
thoroughly irrigated, thorough hemostasis obtained and then a Blake drain was
placed and brought out to the inferior mammary line, sutured in position. The
skin was then closed with staples. Attention was then turned to the left
breast. Again, oblique incision was made. The patient had a prior lumpectomy
with an incision at the inferior mammary line. An oblique incision was marked.
The skin incision made and utilizing a Gorney scissors, skin flaps were
created of appropriate areas. The clavicle superiorly, latissimus dorsi and
laterally, rectus inferiorly and the sternal border medially. Then, there was
breast tissue along with the implant, was reflected from medial to lateral. It
should be noted the axillary tail was removed with the breast. There was very
little axillary tissue noted. The nerves were easily visible along with the
axillary vein. There appeared to be no lymphatic tissue present. There were
no positive palpable issues or actually very little fat in that area. Whatever
was there was removed with the axillary tail. The wound was then thoroughly
irrigated. Hemostasis obtained. A Blake drain was placed, brought out
inferiorly and sutured in position. After obtaining thorough hemostasis and
irrigation, the skin was closed with staples. Firm pressure dressings
including a breast binder were applied. Final sponge, needle, and instrument
count were correct. Sterile dressing was placed. The patient was transferred
to recovery in satisfactory condition.
Help please
