I am wondering if 19112 would be the correct code for the below procedure. Provider also performed debridement and is asking if that changes the CPT. It does not look like the debridement was extensive enough. Wanted to get others thoughts please.
A medial periareolar incision was created along a pre-existing well healed incision from prior incision and drainage. Superficial dissection was commenced sharply and a small fistula tract with calcific change within the dermis was noted. Using a lacrimal probe, a fistula tract was easily passed into the 12:00 position for a distance of 4.5 cm. Multiple additional fistula tracts were identified emanating deep to the nipple in the lateral orientation and further medially. These were debrided using a small curette. The calcific changes within the breast were located primarily along the inferior aspect of the dissection planes. These were excised completed and passed off as a specimen to rule out granulomatous mastitis. The remainder of the surrounding breast tissue appeared denuded, discolored and fatty replaced.
Hemostasis was ensured. The breast parenchyma was reapproximated after mobilization off of the pectoralis muscle using several interrupted 3-0 Vicryl stitches. 0.25% Marcaine with epinephrine was used as local anesthetic. The skin was closed using several interrupted 3-0 Monocryl's followed by a running 4-0 Monocryl in a subcuticular fashion. Sterile dressings were applied. All needle and sponge counts were correct at the end of the case
A medial periareolar incision was created along a pre-existing well healed incision from prior incision and drainage. Superficial dissection was commenced sharply and a small fistula tract with calcific change within the dermis was noted. Using a lacrimal probe, a fistula tract was easily passed into the 12:00 position for a distance of 4.5 cm. Multiple additional fistula tracts were identified emanating deep to the nipple in the lateral orientation and further medially. These were debrided using a small curette. The calcific changes within the breast were located primarily along the inferior aspect of the dissection planes. These were excised completed and passed off as a specimen to rule out granulomatous mastitis. The remainder of the surrounding breast tissue appeared denuded, discolored and fatty replaced.
Hemostasis was ensured. The breast parenchyma was reapproximated after mobilization off of the pectoralis muscle using several interrupted 3-0 Vicryl stitches. 0.25% Marcaine with epinephrine was used as local anesthetic. The skin was closed using several interrupted 3-0 Monocryl's followed by a running 4-0 Monocryl in a subcuticular fashion. Sterile dressings were applied. All needle and sponge counts were correct at the end of the case