SHOEMAKER1987
New
Any help/insights would be greatly appreciated. I am leaning towards the 19110 but we are being told to bill it as 19120.
NAME OF PROCEDURE: Right breast mass and terminal duct excision.
PREOPERATIVE DIAGNOSIS: Right breast periductal mastitis.
POSTOPERATIVE DIAGNOSIS: Right breast periductal mastitis.
INDICATIONS: Female who presents with right breast periductal mastitis. She has had 10 or 12 infections in the same area at the right breast upper outer quadrant right at the nipple areolar complex normal skin border. This presentation is consistent with periductal mastitis. The risks, benefits, and indications of right breast inflammatory mass with terminal duct and central nipple duct incision had been discussed in length and detail with the patient. She relays understanding and desires to proceed. Informed consent was obtained and placed upon the chart.
DESCRIPTION OF OPERATIVE PROCEDURE: The patient was properly identified, taken to the operating room, and placed supine upon the operating table after the establishment of the monitored anesthesia care with general anesthesia and admission of perioperative prophylactic antibiotic, the right breast was prepped and draped in the standard surgical fashion. The skin of the right breast was then anesthetized with 0.5% Marcaine without epinephrine prior to making an incision. Thus, an elliptical incision incorporating the inflammatory mass at the right breast upper outer quadrant right at the nipple areolar complex normal skin border was then made and carried down through the skin and subcutaneous tissues. The dissection then proceeded subcutaneously up to the level of the nipple. The terminal ducts were then divided. The central nipple ducts were then excised and passed off the table with the specimen. The nipple was then reapproximated using a buried dermal 4-0 Vicryl suture. This having been completed, the terminal ducts were then excised along with the inflammatory mass and accompanying skin. These were then passed off the table as a specimen. Subcutaneous flaps were then raised circumferentially and the breast tissue was reapproximated using 2-0 Vicryl in a figure-of-eight fashion. This having been completed, the nipple normal skin was then reapproximated using a series of buried dermal sutures of 2-0 Vicryl and the skin was then closed using a 4-0 Vicryl in a running subcuticular fashion. Mastisol, followed by Steri-Strips, followed by sterile dressings were applied. The patient was then awakened from anesthesia, had LMA removed, and was transported to the recovery room, awake, alert, and in stable condition, having tolerated the procedure well. FINDINGS: Right breast periductal mastitis excised without difficulty including terminal ducts and central nipple ducts.
NAME OF PROCEDURE: Right breast mass and terminal duct excision.
PREOPERATIVE DIAGNOSIS: Right breast periductal mastitis.
POSTOPERATIVE DIAGNOSIS: Right breast periductal mastitis.
INDICATIONS: Female who presents with right breast periductal mastitis. She has had 10 or 12 infections in the same area at the right breast upper outer quadrant right at the nipple areolar complex normal skin border. This presentation is consistent with periductal mastitis. The risks, benefits, and indications of right breast inflammatory mass with terminal duct and central nipple duct incision had been discussed in length and detail with the patient. She relays understanding and desires to proceed. Informed consent was obtained and placed upon the chart.
DESCRIPTION OF OPERATIVE PROCEDURE: The patient was properly identified, taken to the operating room, and placed supine upon the operating table after the establishment of the monitored anesthesia care with general anesthesia and admission of perioperative prophylactic antibiotic, the right breast was prepped and draped in the standard surgical fashion. The skin of the right breast was then anesthetized with 0.5% Marcaine without epinephrine prior to making an incision. Thus, an elliptical incision incorporating the inflammatory mass at the right breast upper outer quadrant right at the nipple areolar complex normal skin border was then made and carried down through the skin and subcutaneous tissues. The dissection then proceeded subcutaneously up to the level of the nipple. The terminal ducts were then divided. The central nipple ducts were then excised and passed off the table with the specimen. The nipple was then reapproximated using a buried dermal 4-0 Vicryl suture. This having been completed, the terminal ducts were then excised along with the inflammatory mass and accompanying skin. These were then passed off the table as a specimen. Subcutaneous flaps were then raised circumferentially and the breast tissue was reapproximated using 2-0 Vicryl in a figure-of-eight fashion. This having been completed, the nipple normal skin was then reapproximated using a series of buried dermal sutures of 2-0 Vicryl and the skin was then closed using a 4-0 Vicryl in a running subcuticular fashion. Mastisol, followed by Steri-Strips, followed by sterile dressings were applied. The patient was then awakened from anesthesia, had LMA removed, and was transported to the recovery room, awake, alert, and in stable condition, having tolerated the procedure well. FINDINGS: Right breast periductal mastitis excised without difficulty including terminal ducts and central nipple ducts.