Hi list,
I am confident on the 19301 but not sure about the 3xxx codes, can someone please point me in the right direction?
tia
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Breast Cancer, right Breast
POSTOPERATIVE DIAGNOSIS:
Breast Cancer, right Breast
PROCEDURE PERFORMED: Right Axillary Sentinel Lymph Node Biopsy and right breast lumpectomy (partial mastectomy).
ANESTHESIA:
General Laryngeal Mask Airway Anesthesia
ANESTHETIST:
SURGEON:
INDICATIONS:
is a 68 y.o. female with a right breast mass. She has had a previous mammogram and ultrasound. The mass is palpable in the 6 o'clock position in the right breast. Previous needle biopsy was positive for carcinoma. At this time a lumpectomy/partial mastectomy and sentinel axillary lymph node dissection is recommended. The patient understands that additional surgery and treatment may be necessary depending upon the final histological diagnosis. All questions voiced bywere addressed and fully answered prior to the procedure.
DESCRIPTION OF PROCEDURE:
The patient has had injection of the isotope preoperatively, and the sentinel lymph node mapping was personally reviewed with the radiologist. The patient was brought to the operating room. With the patient in a supine position, a time-out was called and she was identified by name and intended procedure. Preoperative antibiotics were administered. Intermittent venous compression pumps were applied to both lower extremities. Total intravenous anesthesia was administered. The right breast and axilla were prepped and draped in the usual sterile fashion. The areas over the proposed incisions were preemptively anesthetized with 0.5% Marcaine. A short transverse right axillary incision was made along the inferior axillary hairline and carried through the subcutaneous tissue to the chest wall. The axillary dissection was bordered anteriorly by the lateral edge of the pectoralis major muscle, inferiorly by the latissimus dorsi muscle, and superiorly by the axillary vein. Lymph nodes in the area were identified and measured for isotope uptake. The lymph nodes with the highest uptake counts of 2540 were excised and submitted for permanent histological examination and labeled as the "sentinel lymph nodes". Hemostasis was obtained, the axillary subcutaneous tissue was closed with interrupted 3/0 Vicryl sutures, and the skin was closed with a running 4/0 Monocryl subcuticular suture.
Attention was then turned to the breast mass. A short transverse incision was made in the inferior right mammary skin crease near the mass and carried sharply through the skin and subcutaneous tissue. Skin flaps were raised superiorly and inferiorly as appropriate. The mass with a margin of surrounding breast tissue was excised. The mass was removed from the table and submitted for a specimen radiograph which confirmed the previously-placed biopsy clip in the center of the specimen. The specimen was then submitted for permanent histological evaluation and tumor markers. The surgical site was irrigated with saline and suctioned dry. Hemostasis appeared excellent.
The area was further anesthetized with 0.5% Marcaine. The deep breast tissue was closed with interrupted 3-0 Vicryl sutures, and the skin was closed with a running 4-0 Monocryl subcuticular suture. Dermabond was applied as a dressing. The patient was awakened from anesthesia and transferred to the recovery room, having tolerated the procedure well. All counts were correct.
I am confident on the 19301 but not sure about the 3xxx codes, can someone please point me in the right direction?
tia
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Breast Cancer, right Breast
POSTOPERATIVE DIAGNOSIS:
Breast Cancer, right Breast
PROCEDURE PERFORMED: Right Axillary Sentinel Lymph Node Biopsy and right breast lumpectomy (partial mastectomy).
ANESTHESIA:
General Laryngeal Mask Airway Anesthesia
ANESTHETIST:
SURGEON:
INDICATIONS:
is a 68 y.o. female with a right breast mass. She has had a previous mammogram and ultrasound. The mass is palpable in the 6 o'clock position in the right breast. Previous needle biopsy was positive for carcinoma. At this time a lumpectomy/partial mastectomy and sentinel axillary lymph node dissection is recommended. The patient understands that additional surgery and treatment may be necessary depending upon the final histological diagnosis. All questions voiced bywere addressed and fully answered prior to the procedure.
DESCRIPTION OF PROCEDURE:
The patient has had injection of the isotope preoperatively, and the sentinel lymph node mapping was personally reviewed with the radiologist. The patient was brought to the operating room. With the patient in a supine position, a time-out was called and she was identified by name and intended procedure. Preoperative antibiotics were administered. Intermittent venous compression pumps were applied to both lower extremities. Total intravenous anesthesia was administered. The right breast and axilla were prepped and draped in the usual sterile fashion. The areas over the proposed incisions were preemptively anesthetized with 0.5% Marcaine. A short transverse right axillary incision was made along the inferior axillary hairline and carried through the subcutaneous tissue to the chest wall. The axillary dissection was bordered anteriorly by the lateral edge of the pectoralis major muscle, inferiorly by the latissimus dorsi muscle, and superiorly by the axillary vein. Lymph nodes in the area were identified and measured for isotope uptake. The lymph nodes with the highest uptake counts of 2540 were excised and submitted for permanent histological examination and labeled as the "sentinel lymph nodes". Hemostasis was obtained, the axillary subcutaneous tissue was closed with interrupted 3/0 Vicryl sutures, and the skin was closed with a running 4/0 Monocryl subcuticular suture.
Attention was then turned to the breast mass. A short transverse incision was made in the inferior right mammary skin crease near the mass and carried sharply through the skin and subcutaneous tissue. Skin flaps were raised superiorly and inferiorly as appropriate. The mass with a margin of surrounding breast tissue was excised. The mass was removed from the table and submitted for a specimen radiograph which confirmed the previously-placed biopsy clip in the center of the specimen. The specimen was then submitted for permanent histological evaluation and tumor markers. The surgical site was irrigated with saline and suctioned dry. Hemostasis appeared excellent.
The area was further anesthetized with 0.5% Marcaine. The deep breast tissue was closed with interrupted 3-0 Vicryl sutures, and the skin was closed with a running 4-0 Monocryl subcuticular suture. Dermabond was applied as a dressing. The patient was awakened from anesthesia and transferred to the recovery room, having tolerated the procedure well. All counts were correct.