PREOPERATIVE DIAGNOSIS: Open wound of right breast inframammary area, 2.1 cm.
POSTOPERATIVE DIAGNOSIS: Open wound of right breast inframammary area, 2.1 cm.
PROCEDURE PERFORMED: Debridement and secondary closure of wound, right breast.
PROCEDURE: The patient was brought to the operative suite. She was monitored and sedated. Her breast was prepped with ChloraPrep and appropriately draped. Using a #15 blade, an elliptical excision of this open wound on the underside of the breast was performed followed by Bovie cautery. The underlying implant was removed and the pocket irrigated with saline. Undermining laterally and inferiorly was done with cutting cautery followed by placing the implant back in the pocket and performing a layered closure with 3-0 Vicryl and 4-0 Prolene. Neosporin ointment, Adaptic, and gauze were placed on the wound.
No complications were met with. No antibiotics were given. The patient tolerated the procedure well and left the operating room in satisfactory condition.
The MD thinks an appropriate CPT code would be 19499 for this procedure. Does anyone have any other thoughts?
POSTOPERATIVE DIAGNOSIS: Open wound of right breast inframammary area, 2.1 cm.
PROCEDURE PERFORMED: Debridement and secondary closure of wound, right breast.
PROCEDURE: The patient was brought to the operative suite. She was monitored and sedated. Her breast was prepped with ChloraPrep and appropriately draped. Using a #15 blade, an elliptical excision of this open wound on the underside of the breast was performed followed by Bovie cautery. The underlying implant was removed and the pocket irrigated with saline. Undermining laterally and inferiorly was done with cutting cautery followed by placing the implant back in the pocket and performing a layered closure with 3-0 Vicryl and 4-0 Prolene. Neosporin ointment, Adaptic, and gauze were placed on the wound.
No complications were met with. No antibiotics were given. The patient tolerated the procedure well and left the operating room in satisfactory condition.
The MD thinks an appropriate CPT code would be 19499 for this procedure. Does anyone have any other thoughts?