tsaunders10
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Was trying to determine the correct procedure code to use for this procedure. I have been given 19110 & also 11920 Can anyone help me? I have attached the op report.
PREOPERATIVE DIAGNOSIS:
Left nipple discharge.
POSTOPERATIVE DIAGNOSIS:
Left nipple discharge.
PROCEDURE:
Subareolar duct excision, left breast.
SURGEON:
ASSISTANT:
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
5 mL.
SPECIMEN:
Subareolar duct.
BRIEF H&P:
The patient is a 42-year-old female who presented to my office with persistent left nipple discharge. Her imaging
was negative. Of note, she has had 3 previous breast/nipple surgeries at the site starting approximately 9 years
ago. I did discuss with patient, at length, the possibility of excision of the ducts in this area. Indications,
benefits, alternatives and risks of the procedure include, but are not limited to infection, bleeding, damage to
surrounding structures, nipple necrosis, decreased cosmesis of the breast, need for additional surgeries or
procedures, persistent drainage, possible need for return to the OR, as well as the risks of anesthesia. These were
discussed the patient and she agrees to proceed.
DESCRIPTION OF PROCEDURE:
The patient was identified in the preoperative area. Her left breast and nipple were confirmed as the site of the
procedure. She was taken to the operating room, placed on the table in the supine position. General anesthesia
was induced. Patient was prepped and draped in the usual sterile fashion. Time-out was completed verifying
the correct patient, procedure, and site. Again, the left side was confirmed as the correct side. My signature was
noted within the operative field. Local anesthetic was injected in the infra-areolar region. A curvilinear incision
was then created in the subareolar area. Adson's were used to grasp and elevate. The areola and the tissue was
dissected. We do attempt to probe the area. The probe does not pass externally into the internal region. With
further palpation, we do feel it appears to be a hard mass attached to the undersurface of the nipple.
It does
appear to be a cyst wall. This area and the surrounding duct tissue was excised and sent to Pathology. Good
hemostasis was seen. The nipple was reapproximated with both Vicryl in interrupted fashion and Monocryl in a
pursestring fashion. Our incisions then reapproximated with deep dermals and Vicryl in an interrupted fashion.
Finally, the skin was closed with 4-0 Monocryl in a running, subcuticular fashion. Skin was cleaned, dried and
covered with Dermabond, gauze and tape.
All sponge and instrument counts x2 were correct at the end the procedure.
The patient tolerated the procedure well and was returned to the recovery area in stable condition
PREOPERATIVE DIAGNOSIS:
Left nipple discharge.
POSTOPERATIVE DIAGNOSIS:
Left nipple discharge.
PROCEDURE:
Subareolar duct excision, left breast.
SURGEON:
ASSISTANT:
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
5 mL.
SPECIMEN:
Subareolar duct.
BRIEF H&P:
The patient is a 42-year-old female who presented to my office with persistent left nipple discharge. Her imaging
was negative. Of note, she has had 3 previous breast/nipple surgeries at the site starting approximately 9 years
ago. I did discuss with patient, at length, the possibility of excision of the ducts in this area. Indications,
benefits, alternatives and risks of the procedure include, but are not limited to infection, bleeding, damage to
surrounding structures, nipple necrosis, decreased cosmesis of the breast, need for additional surgeries or
procedures, persistent drainage, possible need for return to the OR, as well as the risks of anesthesia. These were
discussed the patient and she agrees to proceed.
DESCRIPTION OF PROCEDURE:
The patient was identified in the preoperative area. Her left breast and nipple were confirmed as the site of the
procedure. She was taken to the operating room, placed on the table in the supine position. General anesthesia
was induced. Patient was prepped and draped in the usual sterile fashion. Time-out was completed verifying
the correct patient, procedure, and site. Again, the left side was confirmed as the correct side. My signature was
noted within the operative field. Local anesthetic was injected in the infra-areolar region. A curvilinear incision
was then created in the subareolar area. Adson's were used to grasp and elevate. The areola and the tissue was
dissected. We do attempt to probe the area. The probe does not pass externally into the internal region. With
further palpation, we do feel it appears to be a hard mass attached to the undersurface of the nipple.
It does
appear to be a cyst wall. This area and the surrounding duct tissue was excised and sent to Pathology. Good
hemostasis was seen. The nipple was reapproximated with both Vicryl in interrupted fashion and Monocryl in a
pursestring fashion. Our incisions then reapproximated with deep dermals and Vicryl in an interrupted fashion.
Finally, the skin was closed with 4-0 Monocryl in a running, subcuticular fashion. Skin was cleaned, dried and
covered with Dermabond, gauze and tape.
All sponge and instrument counts x2 were correct at the end the procedure.
The patient tolerated the procedure well and was returned to the recovery area in stable condition