Wiki Revision of Mastectomy

[MSUEEMBRY]

Patient had Modified Radical Mastectomy on 11/7/13, (breast CA) the path report shows that there are further tumors that need to be removed. the doctor took the patient back to surgery on 01/13/14 (patient still in surgical global period) the doctor said he did a revision of the mastectomy, I need help big time for CPT codes. Op note is as follows:

General anesthesia was used.
Right chest prepped/draped in sterile fashion. the patient had a previous modified radical mastectomy. Path shows further tumors, therefore we marked the incision in order to excise the medial segment of the previously created transverse incision. Revision of mastectomy with excision of skin of right chest wall medially especially at the medial aspect of transverse incision was excised elliptically, the size of the specimen is 5CM wide, up and down 4 CM, and the depth is 1 CM down to the chest wall musculature and to the tendons connective tissue of the sternum. the subcutaneous tissue was mobilized, superior and inferior flap was mobilized with the cautery and the wound was closed in layers with interrupted subcuticular absorbable sutures and permanent interrupted permanent sutures, Patient tolerated well.

I am thinking about using 21554-58 or 21558-58 NEED HELP!!!!!!!

 

[tlivengo]

re-excision mastectomy

The re-excision of breast tissue is reported with code 19301. Additionally, because the procedure is clinically likely to occur within the usual postoperative period, modifier 58 should be appended to indicate that this is a related procedure by the same physician during the postoperative period