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Consider this otolaryngology case study to decide when to append modifier 25. The Cigna Group recently postponed a requirement for documentation to be submitted with all claims that include a 25 modified office or other outpatient evaluation and management (E/M) service (CPT® 99212-99215) and a minor procedure. Although the payer didn’t follow through on this […]
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Look for them at a hospital near you. The ICD-10-PCS update for fiscal year 2023 is now available. To prevent coding errors that result in claim denials, inpatient coders should download the code files and familiarize themselves with the changes to inpatient coding that go into effect Oct. 1. The fiscal year (FY) 2023 ICD-10-PCS […]
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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.
*
Need your expertise on this procedure, which is denied by Medi-Cal.
Does anyone know what was the code(s) used prior to 2016 when this procedure was performed?
Or how we can bill this to Medi-Cal?
Thanks,
Fami
Thank you in advance!
PROCEDURE: Exploratory laparotomy. Rectosigmoid resection. Mobilization of the right colon, hepatic and splenic flexures. Debridement of right retroperitoneal space.
A standard midline incision was performed. Prior to entering the peritoneal cavity, there was a purulent infection noted coming from the right lower quadrant and right mid abdominal retroperitoneal space. Upon entering the abdominal cavity, there was murky peritoneal fluid but no obvious succus entericus identified. The omentum was matted and fixed to a pelvic inflammatory/neoplastic mass. The omentum was mobilized by dividing it between Kelly clamps and tying off with 0 silk suture. Loops of the terminal ileum or fixed to the mass as well but not incorporated by it. The inflammatory adhesions were taken down freeing the small intestine from the pelvic mass.
*
Once it was decided that the the pelvic mass was the probable source of perforation and sepsis and resection was eminent, the right hemiabdomen was explored by mobilizing the right colon. There was evidence of a previous appendectomy. The right ureter was identified. There was a foul-smelling diffuse infectious process involving the soft tissues of the right retroperitoneum, incorporating the renal space. The hepatic flexure was mobilized and the duodenum exposed. There is no bile staining in the sub-hepatic space and the duodenum appeared intact and without inflammation as did the stomach and gallbladder. The NG tube was palpated. The liver appeared normal. There is a small hemangioma in the left hepatic lobe. The necrotic tissue of the right retroperitoneal space was excised.
*
The small bowel was run from the ligament of Treitz to the ileocecal valve and there is no evidence of perforation or malignancy. The transverse colon was palpated and normal. The left colonsigmoid colon junction was then divided with a TA stapler. Mesentery was scored medially and the left colon/sigmoid avascular line was incised to fully mobilize the left colon and sigmoid. The sigmoid colon mesentery was divided between Kelly clamps and tied off with 0 silk suture. Left ureter was identified and protected. The inflammatorypossibly neoplastic mass was then mobilized from the pelvic sidewall. Upon dividing the dense tissue surrounding the mass, a small colotomy was created. The posterior rectal space was entered allowing for isolation of the lateral stalks that were divided under direct vision using sharp dissection and cautery. The inflamed anterior space was entered as well allowing for the contour stapler to encompass the superior rectum for excision of the rectosigmoid. 0 Prolene sutures were placed on the lateral aspect of the superior rectum for future identification. The left colon was viable and mobilized to the splenic flexure.
*
Anesthesia department reported difficulty maintaining the patient’s blood pressure despite maximum fluids and pressor agents. Therefore the decision was made to irrigate the abdomen with several liters of warm saline and to place an AB Thera device for closure and to take the patient back for a second look in 24-48 hours. There was diffuse oozing from the right retroperitoneal space. Upon mobilizing the liver by dividing the ligamentum teres, there was a small tear made in the left lobe that was cauterized and a small piece of Surgicel placed for hemostasis. Otherwise there is no significant bleeding. Sponge needle count was correct. The abdomen Ab Thera was placed to vacuum suction with a good seal. The patient was then taken to the intensive care unit intubated and stable but in critical condition.
*
*
PREOPERATIVE DIAGNOSIS:
Right below-knee amputation stump ulcer.
POSTOPERATIVE DIAGNOSIS:
Right below-knee amputation stump ulcer.
PROCEDURE PERFORMED:
Right below-knee amputation stump wound revision.
ANESTHESIA:
General with Dr. English.
ESTIMATED BLOOD LOSS:
5 cc.
FINDINGS:
Benign-appearing ulcer at the BKA stump. It was excised, debrided, and closed
primarily.
DETAILS OF THE PROCEDURE:
The patient is a 68-year-old female with prior below-knee amputation, developed
a necrotic wound and ulcer. She was consented for surgery, brought to OR in
supine position, sedated, and intubated without complication. Time-out per
protocol. Preoperative antibiotics given. The right BKA stump was prepped and
draped in the usual sterile fashion. A sharp dissection was used to excise the
tissue around that area and debrided down to healthy bleeding normal tissue.
Then, I proceeded to excise the ulcer itself and down to subcu and muscle and
fat were well-perfused tissue. Then, the wound was widened to create an
ellipse and close primarily with 2-0 nylon in an interrupted fashion. The
patient tolerated the procedure well, and she was extubated and returned to
PACU with vital signs stable.