Wiki revision of mastectomy scar

[kiku3@ptd.net]

Really need help with this one:

Proced. performed: revision of left mastectomy scar, with excision of inferior margarins.

Indications for proced: invavasive lobular CA, status post mastectomy, with positive inferior margins on the pathological specimen evaluation

Proced: left breast scar area and chest prepped and draped; using a #15 blade, 1 cm margin of the entire inferior aspect of the mastectomy scar were then excised, full thickness. electrocautery was used to maintain hemostasis, skin sent to path for further eval. mastectomy wound was then copiously irrigated with normal sline and then cloosed in layers

this is a watered-down report, I just put in the vital facts, the mastectomy was done only 3 days earlier, but how do I bill for this procedure, and I am assuming I would use a modifier 78 along with it.

Thank you for any and all help!!1

 

[tcooper@nmhs.net]

We use the Mastectomy code that was used on the first code along with the 58 modifier. We use the 58 because this was a more extensive procedure to get clear margins. I hope this helps.