jdibble
True Blue
Hi all! Can someone look at this note and give me feedback on what codes to use? I originally was going to use 19370-50, 11907-50, dx V51.0, V45.71, V10.3, but then I saw info on here that I should use 19342-50 instead. The doctor wants the first code set because the RVU's are higher with dx 174.9. 
PREOPERATIVE DIAGNOSIS: Bilateral breast cancer.
POSTOPERATIVE DIAGNOSIS: Bilateral breast cancer.
PROCEDURES PERFORMED: Exchange of tissue expanders for bilateral permanent saline implants, capsulotomies bilaterally, and contouring the capsule in order to facilitate symmetry.
ANESTHESIA: General
OPERATIVE FINDINGS: The tissue expanders were intact that were removed and the replacement implants on the left side were a Natrelle saline-filled breast implant, Style 68MP. The total volume of saline was 240 cc, reference #68-210, serial #16015639. On the right side, Natrelle saline-filled breast implant, 68MP is the style number, reference #68-210, serial #15179004, 240 cc of saline total volume.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room and prepped and draped in the routine sterile fashion. A time-out was performed. The existing incisions were marked out along the breasts. On the right side, care was taken to avoid re-incising the portion of the incision that had problems with wound healing. On the left side, there were no problems with wound healing and the incision was recreated. The patient had markings done in the preoperative holding area. These were used as guides and marked with methylene blue in the operating room. The incisions were injected with local anesthetic containing epinephrine and then some of the key areas along the breast pockets were injected as well. The incisions were created sharply, full thickness, through skin into subcutaneous tissue. Immediately, the tissue around the implant was visible. Subcutaneous undermining was performed inferiorly in a stair-step manner of gaining access onto the breast implant. The capsule and AlloDerm interface was incised transversely and the expanders were immediately visible. The expanders were removed and passed off as a gross pathology specimen. The breast envelopes were carefully evaluated. The capsules appeared mature. The AlloDerm was well incorporated and there were no problems. There was existing asymmetries in the breast shape and in order to facilitate as symmetrical as possible a result, capsule scoring was performed along the base of the capsule in key areas as well as tangential scoring anteriorly along the capsule in 2 areas on the right breast and in 1 area on the left breast. There was additional contouring of the inframammary fold on the left breast in order to facilitate a smoother breast implant contour. Sizers were then brought into the field. The patient was sat up and it was determined that the final size of the breast would be approximately 240 cc of saline in the implant. The sizers were removed and then the permanent breast implants were brought up to the field. The breast envelopes were carefully irrigated with saline. Hemostasis was rechecked prior to closure and then a triple antibiotic solution was instilled into the breasts, then allowed to fit while the implants were being prepared. The implants were placed in a triple antibiotic solution using a no-touch technique and there were no complications during the closed filling system. A total of 240 cc of saline were placed into each saline breast implant. Closure was performed in layers with a deep dermal 4-0 interrupted PDS suture followed by a running subcuticular closure and Dermabond. Hemostasis was maintained during the case with the Bovie. The patient had a surgical bra placed at the end of the case. The patient had no intraoperative complications. She was awoken in the operating room without complications. She was taken to the recovery with a LMA in place on a T-piece and later that was removed without problems.
Please let me know which is the correct CPT and DX for this note!
Thanks,
PREOPERATIVE DIAGNOSIS: Bilateral breast cancer.
POSTOPERATIVE DIAGNOSIS: Bilateral breast cancer.
PROCEDURES PERFORMED: Exchange of tissue expanders for bilateral permanent saline implants, capsulotomies bilaterally, and contouring the capsule in order to facilitate symmetry.
ANESTHESIA: General
OPERATIVE FINDINGS: The tissue expanders were intact that were removed and the replacement implants on the left side were a Natrelle saline-filled breast implant, Style 68MP. The total volume of saline was 240 cc, reference #68-210, serial #16015639. On the right side, Natrelle saline-filled breast implant, 68MP is the style number, reference #68-210, serial #15179004, 240 cc of saline total volume.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room and prepped and draped in the routine sterile fashion. A time-out was performed. The existing incisions were marked out along the breasts. On the right side, care was taken to avoid re-incising the portion of the incision that had problems with wound healing. On the left side, there were no problems with wound healing and the incision was recreated. The patient had markings done in the preoperative holding area. These were used as guides and marked with methylene blue in the operating room. The incisions were injected with local anesthetic containing epinephrine and then some of the key areas along the breast pockets were injected as well. The incisions were created sharply, full thickness, through skin into subcutaneous tissue. Immediately, the tissue around the implant was visible. Subcutaneous undermining was performed inferiorly in a stair-step manner of gaining access onto the breast implant. The capsule and AlloDerm interface was incised transversely and the expanders were immediately visible. The expanders were removed and passed off as a gross pathology specimen. The breast envelopes were carefully evaluated. The capsules appeared mature. The AlloDerm was well incorporated and there were no problems. There was existing asymmetries in the breast shape and in order to facilitate as symmetrical as possible a result, capsule scoring was performed along the base of the capsule in key areas as well as tangential scoring anteriorly along the capsule in 2 areas on the right breast and in 1 area on the left breast. There was additional contouring of the inframammary fold on the left breast in order to facilitate a smoother breast implant contour. Sizers were then brought into the field. The patient was sat up and it was determined that the final size of the breast would be approximately 240 cc of saline in the implant. The sizers were removed and then the permanent breast implants were brought up to the field. The breast envelopes were carefully irrigated with saline. Hemostasis was rechecked prior to closure and then a triple antibiotic solution was instilled into the breasts, then allowed to fit while the implants were being prepared. The implants were placed in a triple antibiotic solution using a no-touch technique and there were no complications during the closed filling system. A total of 240 cc of saline were placed into each saline breast implant. Closure was performed in layers with a deep dermal 4-0 interrupted PDS suture followed by a running subcuticular closure and Dermabond. Hemostasis was maintained during the case with the Bovie. The patient had a surgical bra placed at the end of the case. The patient had no intraoperative complications. She was awoken in the operating room without complications. She was taken to the recovery with a LMA in place on a T-piece and later that was removed without problems.
Please let me know which is the correct CPT and DX for this note!
Thanks,