I have a surgeon who performed a mastectomy including axillary lymph nodes, lower portion of the major pectoralis muscle but no minor pectoralis muscles.
19307 does not seem appropriate since a portion of the major pectoralis muscle was excise. 19305 includes both major/minor pectoralis muscles. . Below is a portion of the op report:
"Then attention paid to the left breast where a large mass noted with skin retraction in the upper outer quadrant. Using a plasma blade an elliptical incision was made on the left breast that included the nipple-areolar complex. The superior flap was raised sharply to the upper breast margin at the chest wall to the inferior aspect of the clavicle, medially to the parasternal border, inferiorly to the inframammary fold then working laterally the tumor was invaded into the pectoralis muscle full thickness and a portion of the muscles was removed with the specimen. Approximaetly 6-7 cm In its greatest length. Then dissection completed laterally to the latissimus muscle and the axilla superiolaterally."
Any suggestions on how to code this?
Thank you!
19307 does not seem appropriate since a portion of the major pectoralis muscle was excise. 19305 includes both major/minor pectoralis muscles. . Below is a portion of the op report:
"Then attention paid to the left breast where a large mass noted with skin retraction in the upper outer quadrant. Using a plasma blade an elliptical incision was made on the left breast that included the nipple-areolar complex. The superior flap was raised sharply to the upper breast margin at the chest wall to the inferior aspect of the clavicle, medially to the parasternal border, inferiorly to the inframammary fold then working laterally the tumor was invaded into the pectoralis muscle full thickness and a portion of the muscles was removed with the specimen. Approximaetly 6-7 cm In its greatest length. Then dissection completed laterally to the latissimus muscle and the axilla superiolaterally."
Any suggestions on how to code this?
Thank you!