Hi list,
I am still fairly new to Surgery coding. Would you use 11970-50 OR 19342-50?? Need some input please.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS(ES):
1. History of breast cancer. S/p remote bilateral mastectomy and chemotherapy.
2. Status post immediate staged breast reconstruction with NSM, bilateral breasts,
with Tissue expander and AlloDerm.
3. Deformity bilateral breasst.
4. Breast asymmetry.
POSTOPERATIVE DIAGNOSIS(ES):
Same.
OPERATION(S) PERFORMED:
Second stage bilateral breast reconstruction.
1. Removal of bilateral Tissue Expanders
2. Bilateral superior capsulotomy.
3. Bilateral medial capsulotomy.
4. Bilateral strip capsulectomy and plication of the lateral pocket.
5. Placement of silicone impants.
IMPLANT:
1. Mentor smooth round high profile plus silicone gel breast implant
Left Breast:
Reference #350- 5504BC, Serial # 6619911-036.
Right Breast:
Reference #350- 5504 BC, Serial # 6863842-026.
ESTIMATED BLOOD LOSS:
Minimal.
OR FLUIDS:
1200 cc of LR.
COMPLICATIONS:
None.
DRAINS:
1. JP 15-French, 1 each breast.
LOCAL:
7 cc of 1% lidocaine, 1:200,000 epinephrine.
SPECIMENS:
None
ANTIBIOTICS:
Vancomycin 1 g IV piggyback prior to incision and clindamycin 900 mg IV
piggyback prior to incision.
DVT PROPHYLAXIS:
TEDS and SCDs bilateral lower extremities, engaged prior to induction of
Anesthesia. Lovenox prior to operation.
INDICATIONS:
Status post immediate staged tissue expander and AlloDerm breast reconstruction, with deformity of the reconstructed bilateral breast requiring 2nd stage of reconstruction and a procedure for Breast symmetry.
SUMMARY:
The patient was first seen in the preoperative area, where she was marked in the
upright standing position. The midline of the chest wall and planned releases superior and medially were marked. The inframammary folds and
meridian of the breast and anterior axillary line were all marked as well. The plan for plication of the lateral breast was marked as well.
The patient was then taken the operating where she
is placed in supine position on the operating table. Following induction
of general endotracheal anesthesia, the patient's planned incisions in the IMF
were infiltrated with a total of 7cc of 1% lidocaine, 1:200,000
epinephrine. She was prepped and draped in the usual sterile manner.
Time-out was performed with all those in the operating room actively participating.
An incision was made through the previous mastectomy scar in the lateral IMF of the right breast. The dissection continued until the Alloderm was identified. I entered the implant pocket at this point. The tissue expander was deflated and removed through this incision . The right pocket was explored, evaluated and irrigated with triple antibiotic solution (Bacitracin , Gentamycin and Ancef). All Alloderm was integrated. The pocket was too wide laterally and to narrow medially and superiorly. Beginning with the medial pocket a capsulotomy was made just above the chest wall and additional slips of the pectoralis muscle was release along the sternum until it met my marker operaive plan. The superior pocket was than modified by a making a separate capsulotomy at the junction of the chest wall and pec muscle and the plane beneath the muscle was released superiorly. Finally the later pocket was evaluated. The Tissue expander was too far lateralized and the pocket wide in this area. The correct contour and dimension was marked inside and out. A strip capsulectomy was performed and the lateral pick was plicated with deep buried 2-0 Vicryl suture in an interrupted fashion from the IMF to the upper lateral breast. The pocket was irrigated and checked for hemostasis. A 500 cc high profile implant sizer was brought to
the table and placed into the right implant pocket. It had been soaking in the previously identified triple
antibiotic solution. This was removed and a 550CC HP implant was placed and found to be more aesthetic. The wound was stapled shut.
I then turned my attention to the left breast. An incision was made through the previous mastectomy scar in the lateral IMF of the left breast. The dissection continued until the Alloderm was identified. I entered the implant pocket at this point. The tissue expander was deflated and removed through this incision. The right pocket was explored, evaluated and irrigated with triple antibiotic solution (Bacitracin , Gentamycin and Ancef). All Alloderm was integrated. The pocket was too wide laterally and to narrow medially and superiorly. Beginning with the medial pocket a capsulotomy was made just above the chest wall and additional slips of the pectoralis muscle was release along the sternum until it met my marker operaive plan. The superior pocket was than modified by a making a separate capsulotomy at the junction of the chest wall and pec muscle and the plane beneath the muscle was released superiorly. Finally the later pocket was evaluated. The Tissue expander was too far lateralized and the pocket wide in this area. The correct contour and dimension was marked inside and out. A strip capsulectomy was performed and the lateral pick was plicated with deep buried 2-0 Vicryl suture in an interrupted fashion from the IMF to the upper lateral breast. The pocket was irrigated and checked for hemostasis. A 550 cc high profile implant sizer was brought to the table and placed into the right implant pocket. The wound was stapled shut.
The patient was again brought into a sitting position and the breast compared for shape, size and symmetry.
This had achieved reasonable symmetry and these implants were selected. Two permanent 550 cc high profile implants were brought to the table and placed to soak in triple antibiotic solution for 10 minutes. In
this interim, the patient was once again placed supine. Staples were
removed from the bilateral incisions and the sizers removed.
Deep buried 2-0
Polysorb pop-off sutures were placed at the deep capsular level , they were not tied
down, they were placed to hemostats. A JP 15 French drain was placed from the lateral inferior IMF and placed in the inferior portion of the dissection bilaterally, than secured with a 3-0 nylon suture. My gloves were changed, washed in
triple antibiotic solution, a new Deaver and new Army-Navy were dipped in
triple antibiotic solution and placed into the right implant pocket. The implant
was handled only by me, confirmed to be the correct selection and placed atraumatically into the implant pocket. These sutures were tied down, followed by a layer of deep buried
3-0 Polysorb sutures at the deep dermal level, and a running 4-0 subcuticular
Caprosyn suture was placed to complete the closure.
The procedure was repeated on the left side. The implant was placed atraumatically into the right implant pocket and the 2-0 Polysorb sutures were tied down. Another layer of deep buried interrupted 3-0 polysorb sutures were placed at the deep dermal layer. Finally, a running 4-0 subcuticular Caprosyn suture was placed to complete the closure.
The incisions on the biltaeral breasts were then covered with
Dermabond. The patient was then cleansed, and benzoin antibiotic patches and
Steri-Strips were placed over the patient's drain sites. The patient was placed into a soft stretchy bra.
All needle and sponge counts reported equal at the end the case. Patient
tolerated the procedure without difficulty. No untoward side effects were
Noted. She was transferred from the OR to the PACU awake, extubated and in stable condition.
I am still fairly new to Surgery coding. Would you use 11970-50 OR 19342-50?? Need some input please.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS(ES):
1. History of breast cancer. S/p remote bilateral mastectomy and chemotherapy.
2. Status post immediate staged breast reconstruction with NSM, bilateral breasts,
with Tissue expander and AlloDerm.
3. Deformity bilateral breasst.
4. Breast asymmetry.
POSTOPERATIVE DIAGNOSIS(ES):
Same.
OPERATION(S) PERFORMED:
Second stage bilateral breast reconstruction.
1. Removal of bilateral Tissue Expanders
2. Bilateral superior capsulotomy.
3. Bilateral medial capsulotomy.
4. Bilateral strip capsulectomy and plication of the lateral pocket.
5. Placement of silicone impants.
IMPLANT:
1. Mentor smooth round high profile plus silicone gel breast implant
Left Breast:
Reference #350- 5504BC, Serial # 6619911-036.
Right Breast:
Reference #350- 5504 BC, Serial # 6863842-026.
ESTIMATED BLOOD LOSS:
Minimal.
OR FLUIDS:
1200 cc of LR.
COMPLICATIONS:
None.
DRAINS:
1. JP 15-French, 1 each breast.
LOCAL:
7 cc of 1% lidocaine, 1:200,000 epinephrine.
SPECIMENS:
None
ANTIBIOTICS:
Vancomycin 1 g IV piggyback prior to incision and clindamycin 900 mg IV
piggyback prior to incision.
DVT PROPHYLAXIS:
TEDS and SCDs bilateral lower extremities, engaged prior to induction of
Anesthesia. Lovenox prior to operation.
INDICATIONS:
Status post immediate staged tissue expander and AlloDerm breast reconstruction, with deformity of the reconstructed bilateral breast requiring 2nd stage of reconstruction and a procedure for Breast symmetry.
SUMMARY:
The patient was first seen in the preoperative area, where she was marked in the
upright standing position. The midline of the chest wall and planned releases superior and medially were marked. The inframammary folds and
meridian of the breast and anterior axillary line were all marked as well. The plan for plication of the lateral breast was marked as well.
The patient was then taken the operating where she
is placed in supine position on the operating table. Following induction
of general endotracheal anesthesia, the patient's planned incisions in the IMF
were infiltrated with a total of 7cc of 1% lidocaine, 1:200,000
epinephrine. She was prepped and draped in the usual sterile manner.
Time-out was performed with all those in the operating room actively participating.
An incision was made through the previous mastectomy scar in the lateral IMF of the right breast. The dissection continued until the Alloderm was identified. I entered the implant pocket at this point. The tissue expander was deflated and removed through this incision . The right pocket was explored, evaluated and irrigated with triple antibiotic solution (Bacitracin , Gentamycin and Ancef). All Alloderm was integrated. The pocket was too wide laterally and to narrow medially and superiorly. Beginning with the medial pocket a capsulotomy was made just above the chest wall and additional slips of the pectoralis muscle was release along the sternum until it met my marker operaive plan. The superior pocket was than modified by a making a separate capsulotomy at the junction of the chest wall and pec muscle and the plane beneath the muscle was released superiorly. Finally the later pocket was evaluated. The Tissue expander was too far lateralized and the pocket wide in this area. The correct contour and dimension was marked inside and out. A strip capsulectomy was performed and the lateral pick was plicated with deep buried 2-0 Vicryl suture in an interrupted fashion from the IMF to the upper lateral breast. The pocket was irrigated and checked for hemostasis. A 500 cc high profile implant sizer was brought to
the table and placed into the right implant pocket. It had been soaking in the previously identified triple
antibiotic solution. This was removed and a 550CC HP implant was placed and found to be more aesthetic. The wound was stapled shut.
I then turned my attention to the left breast. An incision was made through the previous mastectomy scar in the lateral IMF of the left breast. The dissection continued until the Alloderm was identified. I entered the implant pocket at this point. The tissue expander was deflated and removed through this incision. The right pocket was explored, evaluated and irrigated with triple antibiotic solution (Bacitracin , Gentamycin and Ancef). All Alloderm was integrated. The pocket was too wide laterally and to narrow medially and superiorly. Beginning with the medial pocket a capsulotomy was made just above the chest wall and additional slips of the pectoralis muscle was release along the sternum until it met my marker operaive plan. The superior pocket was than modified by a making a separate capsulotomy at the junction of the chest wall and pec muscle and the plane beneath the muscle was released superiorly. Finally the later pocket was evaluated. The Tissue expander was too far lateralized and the pocket wide in this area. The correct contour and dimension was marked inside and out. A strip capsulectomy was performed and the lateral pick was plicated with deep buried 2-0 Vicryl suture in an interrupted fashion from the IMF to the upper lateral breast. The pocket was irrigated and checked for hemostasis. A 550 cc high profile implant sizer was brought to the table and placed into the right implant pocket. The wound was stapled shut.
The patient was again brought into a sitting position and the breast compared for shape, size and symmetry.
This had achieved reasonable symmetry and these implants were selected. Two permanent 550 cc high profile implants were brought to the table and placed to soak in triple antibiotic solution for 10 minutes. In
this interim, the patient was once again placed supine. Staples were
removed from the bilateral incisions and the sizers removed.
Deep buried 2-0
Polysorb pop-off sutures were placed at the deep capsular level , they were not tied
down, they were placed to hemostats. A JP 15 French drain was placed from the lateral inferior IMF and placed in the inferior portion of the dissection bilaterally, than secured with a 3-0 nylon suture. My gloves were changed, washed in
triple antibiotic solution, a new Deaver and new Army-Navy were dipped in
triple antibiotic solution and placed into the right implant pocket. The implant
was handled only by me, confirmed to be the correct selection and placed atraumatically into the implant pocket. These sutures were tied down, followed by a layer of deep buried
3-0 Polysorb sutures at the deep dermal level, and a running 4-0 subcuticular
Caprosyn suture was placed to complete the closure.
The procedure was repeated on the left side. The implant was placed atraumatically into the right implant pocket and the 2-0 Polysorb sutures were tied down. Another layer of deep buried interrupted 3-0 polysorb sutures were placed at the deep dermal layer. Finally, a running 4-0 subcuticular Caprosyn suture was placed to complete the closure.
The incisions on the biltaeral breasts were then covered with
Dermabond. The patient was then cleansed, and benzoin antibiotic patches and
Steri-Strips were placed over the patient's drain sites. The patient was placed into a soft stretchy bra.
All needle and sponge counts reported equal at the end the case. Patient
tolerated the procedure without difficulty. No untoward side effects were
Noted. She was transferred from the OR to the PACU awake, extubated and in stable condition.