# Wide Excision of Malignant Neoplasm of skin, soft tissue, and muscle on chest wall



## JoannaWelch (Feb 18, 2016)

I would appreciate any assistance in CPT coding of the following procedure note:  This is on a MALE patient.

Wide Excision of Malignant Neoplasm of skin, soft tissue, and muscle on chest wall 10cm

Patient has been noncompliant with plan of treatment for right breast cancer.  A 1.5 cm margins were marked around it based on palpation to remove lesion and any grossly involved tissue.  The tumor measured 10 cm.  It appeared to be still mobile.  There was no palpable masses axilla.  The tumor was sharply excised with the adjacent skin and soft tissue by developing a superior, inferior and medial lateral flaps and down to the pectoralis major.  Vessels were ligated with 3-0 Vicryl or cauterized.  Once the fascia was reached, the fascia was removed with the tumor until the underside of the lesion was reached.  In effect, it was a simple mastectomy that was performed.  Irrigation performed, hemostasis was obtained.  Vessels were tied with 3-0 Vicryl and tissue was reapproximated with O Vicryl, 2-0 Vicryl and 2-0 nylon.

Any suggestions?  I may be overthinking this.........


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## cynthiabrown (Feb 19, 2016)

curious....what does pathology say?


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## JoannaWelch (Feb 25, 2016)

path is malignant neoplasm right breast...........


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## jjhamer1 (Feb 25, 2016)

21552 - Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3cm or greater


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## ltrue (Feb 26, 2016)

*Wide Excision of Malignant Neoplasm*

If the path came back as breast malignancy, I would actually lean towards 19120 instead.  It includes excision all the way down into the fascia and can be done on females and males.


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