I was auditing a chart and think this is coded incorrectly and need a second opinion.
Procedure: Wire localized right breast lumpectomy
The patient was brought to the operating suite where identity and procedure were confirmed. She was placed n the table in supine position. Wire localization was completed prior to this in radiology. General anesthesia was induced. The right breast was prepped and draped steriley. A transverse incision was made inferior to the wire insertion site such as to place it within the domain of the mastectomy incision should that become necessary later. The skin was elevated superiorly and inferiorly and then following the wire track a core of tissue was taken. Because of the proximity of the chest wall the pectoral fascia was taken. Once the specimen was isolated with electrocautery and removed it was marked with a short stitch superficially, a long stictch laterally, a double knotted stitch on the deep margin and a triple knotted stitch on the inferior margin. Specimen mammogram confirmed placement of the lesion within the center of the specimen. The cavity was irrigated. Hemostasis was confirmed. It was then closed in a layered fashion with interrupted inverted 4-0 Vicryl in the dermis and running 4-0 Monocryl subcuticular in the epidermis with the Dermabond skin sealant. The patient tolerated the procedure well and was transferred to the recovery area.
I coded it with 19301. The previous person coded it as 19125. What is the correct way to code this report and do I also code for the mammogram or is that included?
Thanks for any advice!!!
Procedure: Wire localized right breast lumpectomy
The patient was brought to the operating suite where identity and procedure were confirmed. She was placed n the table in supine position. Wire localization was completed prior to this in radiology. General anesthesia was induced. The right breast was prepped and draped steriley. A transverse incision was made inferior to the wire insertion site such as to place it within the domain of the mastectomy incision should that become necessary later. The skin was elevated superiorly and inferiorly and then following the wire track a core of tissue was taken. Because of the proximity of the chest wall the pectoral fascia was taken. Once the specimen was isolated with electrocautery and removed it was marked with a short stitch superficially, a long stictch laterally, a double knotted stitch on the deep margin and a triple knotted stitch on the inferior margin. Specimen mammogram confirmed placement of the lesion within the center of the specimen. The cavity was irrigated. Hemostasis was confirmed. It was then closed in a layered fashion with interrupted inverted 4-0 Vicryl in the dermis and running 4-0 Monocryl subcuticular in the epidermis with the Dermabond skin sealant. The patient tolerated the procedure well and was transferred to the recovery area.
I coded it with 19301. The previous person coded it as 19125. What is the correct way to code this report and do I also code for the mammogram or is that included?
Thanks for any advice!!!