# breast surgery help coding



## chmoor76 (Feb 10, 2012)

POSTOPERATIVE DIAGNOSIS: DCIS of the left breast 
PROCEDURES PERFORMED: Isotope injection, this was all in the left breast, stereotactic wire localization, sentinel node biopsy, left lumpectomy, and insertion of Foley catheter.
ANESTHESIA: Local and general.
INDICATIONS OF THE PROCEDURE: This is a 62-year-old patient of admitted to the hospital for treatment of her left breast carcinoma. This was documented in my admission history and physical.
DESCRIPTION OF THE PROCEDURE: The patient first of all was injected with 500 microcuries of technetium sulfa-colloid intradermally and circumareolarly. The patient was then taken to the stereotactic room where in the lateral orientation after placing the patient in the prone position with left breast going to be opening on the table the area of the prior biopsy was identified. Using a triangulation technique, three Hawkins wires were delivered into the breast at 12 o'clock, 4 o'clock, and 8 o'clock position. She was then taken to the OR where the breast was prepped and draped in the routine fashion. The lesion was very superficial and then in order to be able to obtain an adequate margin closed to the skin I had to remove an ellipse of skin including all three wires in that ellipse. Dye was injected into the patients axilla area to aid locating any sentinel lymph nodes. First thing that we did though was excise the sentinel nodes, making an incision over the point of maximum activity in the axilla, taking the dissection down to the most superficial axilla identifying a hot and blue lymph node. This was excised using Hemoclips and Bovie. The activity of the lymph node was 3300. Using the gamma probe, no further activity was noted in the axilla with the gamma probe. This was closed in two layers with #3-0 Vicryl and #4-0 Vicryl subcuticular sutures. The ellipse of skin was then removed using a curvilinear incision cutting all three wires in the ellipse of skin that was removed. Dissection was taken in depth all the way down to the breast tissue proper removing all of the skin and the breast tissue that was encompassed by the wires. A deep margin was marked with one suture and the inferior margin was marked with two. I performed a radiological examination of the surgical specimen which revealed that the couple of margins might have been little bit close, and the inferior one and both separate margins were then sent for separate pathological examination. Next, through a separate stab incision in the lateral aspect of the breast, a #22 Foley was inserted into the cavity and the balloon was inflated to 30 cc and then, the breast was closed over this creating an adequate cavity in layers using #2-0 and # 3-0 Vicryl interrupted sutures. The skin was closed with subcuticular closure of # 4-0 Vicryl and then I went ahead and checked our cavity using ultrasound. There was good uniform cavity and we had at least 1.5 cc of margin throughout. Being satisfied with this, the Foley was deflated to 15 cc only. Dressing was applied. Also, we noted that the signs and symptoms were negative for carcinoma.


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## JJackson506 (Feb 17, 2012)

See this article from the American College of Surgeons on SLN procedures
http://www.facs.org/fellows_info/bulletin/2011/socioeconomic1111.pdf


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## syllingk (Feb 17, 2012)

It's a little confusing on the note who did the wire loc and the injection of the radioactive isotope. That is usually done by someone other than the surgeon. If that is the case you would bill.


19301
38525-51
38900
dx 233.0


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