maine4me
Guru
Patient was taken to OR due to breast microcalcifications and history of recurrent abscesses, provider indicates the procedure to be Under image guidance SAVI seed localized wide excision, excision of draining sinus tract periareolar, and revision of scar left breast. The dcumentation is similar to documentation from this provider for wide excision of breas lesion with SAVI seed localization, which I code using 19125. It appears there were two areas of microcalcifications excised for which I have selected codes 19125 and 19126. As for the sinus tract excision and scar revision I do not see documentation for that. Please see the procedure description below:
An elliptical incision was created between the 12 and 6 o'clock axis adjacent to the nipple areolar complex where the patient had a history of abscess drainage and wide excision which was causing nipple retraction and for this reason she requested revision of this scar with excision of the sinus tract due to recurrent abscesses in hopes that her nipple would be eviscerated and no longer retracted. The incision was deepened through subcutaneous tissue with electrocautery and flaps were raised in the avascular plane and the SAVI scout localizer was used to localize the first lesion at the 5:30 axis which was excised entirely and placed in the Faxitron where intraoperative specimen readiograph revealed microcalcifiation as well as the SAVI seed and then similarly, at the 3 o'clock axis, the tissue was localized with the SAVI scout localizer and excisied entirely, placed in the Faxitron where intraoperative specimen radiograph revealed the SAVI seed and the microcalcifications to be within the specimen. Satisfied with this, the cavity was irrigated until clear and hemostasis was achieved with short bursts of electrocautery. 0.25% Marcaine was infiltrated in the subcutaneous tissues for a field block analgesis and the breast parenchyma was approximated with 3-0 PDS. The nipple was everted once more and 4-0 chromic sutures were place just beneth this in order to prevent retraction of the nipple subsequently. Thereafter, the dermis was reapproximated with 3-0 PDS in interrupted inverted fashion and the skin reapproximated with 4-0 Monocryl in running cosmetic subcuticular fashion.
Should there be additional codes?
An elliptical incision was created between the 12 and 6 o'clock axis adjacent to the nipple areolar complex where the patient had a history of abscess drainage and wide excision which was causing nipple retraction and for this reason she requested revision of this scar with excision of the sinus tract due to recurrent abscesses in hopes that her nipple would be eviscerated and no longer retracted. The incision was deepened through subcutaneous tissue with electrocautery and flaps were raised in the avascular plane and the SAVI scout localizer was used to localize the first lesion at the 5:30 axis which was excised entirely and placed in the Faxitron where intraoperative specimen readiograph revealed microcalcifiation as well as the SAVI seed and then similarly, at the 3 o'clock axis, the tissue was localized with the SAVI scout localizer and excisied entirely, placed in the Faxitron where intraoperative specimen radiograph revealed the SAVI seed and the microcalcifications to be within the specimen. Satisfied with this, the cavity was irrigated until clear and hemostasis was achieved with short bursts of electrocautery. 0.25% Marcaine was infiltrated in the subcutaneous tissues for a field block analgesis and the breast parenchyma was approximated with 3-0 PDS. The nipple was everted once more and 4-0 chromic sutures were place just beneth this in order to prevent retraction of the nipple subsequently. Thereafter, the dermis was reapproximated with 3-0 PDS in interrupted inverted fashion and the skin reapproximated with 4-0 Monocryl in running cosmetic subcuticular fashion.
Should there be additional codes?