codeseeker
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Requesting help to code the repair following excision of a breast lesion. The doctor indicates he performed local tissue transfer as well as layered closure. Can we bill for both of these two procedures and what codes would we use for the tissue transfer and layered closure? Also, can someone please very briefly explain how these two procedures are performed?
OPERATIVE REPORT:
PREOPERATIVE DIAGNOSIS: left breast mass; POSTOPERATIVE DIAGNOSIS: left breast mass
OPERATION PERFORMED: 1. Left breast lumpectomy with needle localization 2. interpretation of imaging 3. local tissue transfer 10cm2
DESCRIPTION OF PROCEDURE: After informed consent was obtained regarding all benefits, alternatives, risks, complications and limitations of the procedure including the possibility of deformity of the breast due to the large area that needs to be excised, the patient was taken to the Operating Room, was placed supine in the operating table. Preoperative wireless localization was performed with savi scout. The left breast was prepped and draped in usual sterile fashion after confirmation of savi scout localization functioning and a time out was completed. A curvilinear incision was placed over the the area of highest signal of savi scout. We entered the subcutaneous tissue where flaps were raised in all directions. Upon arriving 10mm from the savi scout, an allis forceps were placed on the breast tissue and the breast tissue to be excised was gently elevated. The area was circumferencially dissected out, en-bloc resected and marked with sutures. After complete hemostasis with Bovie electrocoagulation, we irrigated the biopsy cavity with sterile normal saline to confirm hemostatis. Local tissue transfer was performed with a total of 10cm2. The wound was now reconstructed in layers with undyed 2-0 Vicryl sutures and 3-0 vicryl sutures. 3-0 vicryl inverting interrupted sutures for the dermis as well as a running subcuticular suture of 4-0 Monocryl. Steri-Strips and dermabond were applied after clean and dried, and the patient was advised to wear a 24-hours brassiere for the next week, and to return to my office in one week to review the pathology. Complete removal of the specimen was verified by specimen radiography and interpreted by myself. All instrument and gauze count were reported by the RN as correct x2.
OPERATIVE REPORT:
PREOPERATIVE DIAGNOSIS: left breast mass; POSTOPERATIVE DIAGNOSIS: left breast mass
OPERATION PERFORMED: 1. Left breast lumpectomy with needle localization 2. interpretation of imaging 3. local tissue transfer 10cm2
DESCRIPTION OF PROCEDURE: After informed consent was obtained regarding all benefits, alternatives, risks, complications and limitations of the procedure including the possibility of deformity of the breast due to the large area that needs to be excised, the patient was taken to the Operating Room, was placed supine in the operating table. Preoperative wireless localization was performed with savi scout. The left breast was prepped and draped in usual sterile fashion after confirmation of savi scout localization functioning and a time out was completed. A curvilinear incision was placed over the the area of highest signal of savi scout. We entered the subcutaneous tissue where flaps were raised in all directions. Upon arriving 10mm from the savi scout, an allis forceps were placed on the breast tissue and the breast tissue to be excised was gently elevated. The area was circumferencially dissected out, en-bloc resected and marked with sutures. After complete hemostasis with Bovie electrocoagulation, we irrigated the biopsy cavity with sterile normal saline to confirm hemostatis. Local tissue transfer was performed with a total of 10cm2. The wound was now reconstructed in layers with undyed 2-0 Vicryl sutures and 3-0 vicryl sutures. 3-0 vicryl inverting interrupted sutures for the dermis as well as a running subcuticular suture of 4-0 Monocryl. Steri-Strips and dermabond were applied after clean and dried, and the patient was advised to wear a 24-hours brassiere for the next week, and to return to my office in one week to review the pathology. Complete removal of the specimen was verified by specimen radiography and interpreted by myself. All instrument and gauze count were reported by the RN as correct x2.