Excision of nodule, rt breast with placement of implant for reconstruction , left capsulorrhaphy and bilateral capsulotomies.

[carol52]

Hello,
This patient has undergone tissue expander, implant based reconstruction and now comes for nipple -areolar reconstruction
However, she has developed a nodule in the central aspect of the rt breast, which imaging shows a fat necrosis.
The mass extends underneath the area where the nipple areolar reconstruction was to be performed today..
There was some tightness on the rt side that an implant could not be placed, witch equaled the size of the implant on the left side...
she no comes for placement of the new implant on the rt side to match the lt.
Also the lt side her implant has stretched out laterally so the implant is displaced so that would be closed off with a capsulorrhaphy.
Would anyone be able to help with the CPT codes on this one.
Thanks ,
Carol

Surgery was for RT side Mastectomy closure was re-opended Capsulotomies were done superiorly and anteriorly a new implant size was chosen and placed and deep layers were closed.
A mirror image was performed on the left side.

 

[nickelclaw]

need more info for RT breast is she exchanging the expander to implant. Need Op note to help.