AimeeNK31
New
I have just had a case come across my desk that I need help with. The patient has L DCIS, previously had R breast cancer treated with mastectomy and reconstruction. Apparently, at that time, she also had reconstruction done to the left breast. She know presents with disease in the L breast and goes in for simple mastectomy. The surgeon removes the implant during the mastectomy to prepare for the plastic surgeon to revise. There were no current complications from the L breast implant.
Question: should the impant removal be considered inclusive to the mastectomy or can it be billed separately with a modifier? Op report below.
Thanks in advance.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room, placed in supine position, and general endotracheal anesthesia was initiated. Sequential compression devices and
a Foley urinary catheter were placed on induction of anesthesia. The
patient had been marked in the preoperative holding area. She was prepped
and draped in the usual sterile fashion from the chin to the umbilicus.
The proposed incision site was infiltrated with Exparel and an 8 cm
incision was made from the midline along the inframammary fold. This
dissection was carried through the subcutaneous tissue using
electrocautery. The tissue plane between the subcutaneous tissue and the
breast tissue was infiltrated with tumescent fluid using a Byron tumescent
cannula. A 5 mm blunt laparoscopy trocar was then used to further develop
this plane. The Cooper ligament attachments from the subcutaneous tissue
to the breast tissue were then divided using Metzenbaum scissors. The
tissue behind the nipple was divided sharply using Metzenbaum scissors.
Electrocautery was then used to dissect the breast tissue parallel to the
chest wall until the implant capsule was identified. Dissection was
carried along the surface of the implant capsule over the entire surface of
the breast. At this point, I realized that the implant had been replaced
at some point due to a rupture, which was evident from scar tissue and bits
of extra capsular silicone. The existing implant was now lying just at
the inferior surface and slightly anterior to the pectoral muscles. The
breast and capsule were then dissected off the anterior pectoral fascia
using electrocautery. Once free, this breast was marked with a long stitch
laterally, short stitch superiorly and a loop stitch at the nipple.
Further evaluation of the pocket revealed that her initial implant had been
a subpectoral implant. This was evidenced by a separate previous pocket.
Hemostasis was obtained in the wound with electrocautery.
At that point, Dr. W took over for reconstruction and note
dictated separately by himself. The patient tolerated the procedure well.
There were no apparent complications. Prior to placing the tissue
expander, Dr. W infiltrated Exparel in the anterior pectoral
fascia and the muscles, as well as soft tissue surrounding the incision.
Question: should the impant removal be considered inclusive to the mastectomy or can it be billed separately with a modifier? Op report below.
Thanks in advance.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room, placed in supine position, and general endotracheal anesthesia was initiated. Sequential compression devices and
a Foley urinary catheter were placed on induction of anesthesia. The
patient had been marked in the preoperative holding area. She was prepped
and draped in the usual sterile fashion from the chin to the umbilicus.
The proposed incision site was infiltrated with Exparel and an 8 cm
incision was made from the midline along the inframammary fold. This
dissection was carried through the subcutaneous tissue using
electrocautery. The tissue plane between the subcutaneous tissue and the
breast tissue was infiltrated with tumescent fluid using a Byron tumescent
cannula. A 5 mm blunt laparoscopy trocar was then used to further develop
this plane. The Cooper ligament attachments from the subcutaneous tissue
to the breast tissue were then divided using Metzenbaum scissors. The
tissue behind the nipple was divided sharply using Metzenbaum scissors.
Electrocautery was then used to dissect the breast tissue parallel to the
chest wall until the implant capsule was identified. Dissection was
carried along the surface of the implant capsule over the entire surface of
the breast. At this point, I realized that the implant had been replaced
at some point due to a rupture, which was evident from scar tissue and bits
of extra capsular silicone. The existing implant was now lying just at
the inferior surface and slightly anterior to the pectoral muscles. The
breast and capsule were then dissected off the anterior pectoral fascia
using electrocautery. Once free, this breast was marked with a long stitch
laterally, short stitch superiorly and a loop stitch at the nipple.
Further evaluation of the pocket revealed that her initial implant had been
a subpectoral implant. This was evidenced by a separate previous pocket.
Hemostasis was obtained in the wound with electrocautery.
At that point, Dr. W took over for reconstruction and note
dictated separately by himself. The patient tolerated the procedure well.
There were no apparent complications. Prior to placing the tissue
expander, Dr. W infiltrated Exparel in the anterior pectoral
fascia and the muscles, as well as soft tissue surrounding the incision.