jdibble
True Blue
Good Morning! My Plastic Surgeon did surgeries on two different patients for tissue expander removal and permanent implant placement. She wants to bill 19342-50, 19328-50 and 13101, dx V10.3, V45.71. Based on the documentation I only see 11970 - can someone read the notes and give me their opinion on the correct codes? Also why you would code it that way as I have to go back to her and tell her the correct way to code! Thanks for the help! 
Jodi
Please see the following:
First Patient:
PREOPERATIVE DIAGNOSIS: Breast cancer.
POSTOPERATIVE DIAGNOSIS: Breast cancer.
PROCEDURE: Removal of tissue expanders - bilaterally. Placement of silicone implants
bilaterally. Complex Closure 7cm.
OPERATIVE FINDINGS: This patient had a Natrelle silicone filled breast
implant placed in the left breast, reference #20-450, serial #17047531. The
volume was 450 cc, that was on the left side. On the right side, the patient
had a Natrelle 450 cc silicone implant placed which was reference #20-450,
serial #17194729, that was on the right breast.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient
was taken to the operating room. A time-out was performed in which the
patient's name, medical record number, date of birth, site and side of
operation were confirmed and agreed upon by all present. A prophylactic dose
of Kefzol was given prior to incision. The patient had sequential compression
devices on her calves prior to the induction of the anesthesia. The chest
wall was prepped and draped in the routine sterile fashion. The existing
incisions were marked out and then a 6 cm incision at the existing scar
was created sharply on each side after using 1% lidocaine with epinephrine in a field block. The capsule was encountered, entered and the expanders were removed. Saline irrigation was performed and then sizers were used to confirm a volume of 450 cc on each side. The areas were copiously irrigated with triple antibiotic solution and
then silicone implants were brought up to the field. Dog ear excisions were marked out along the breast skin bilaterally. The total length of excess skin excision was 7cm. The dog ears consisting of skin and subcutaneous tissue were sharply excised using a 15 blade. These were passed off as pathology specimens from the left and right breast. The resultant defects were then closed in layers, deep dermals followed by running subcuticular closure. The breast implant access incisions also were closed in layers, deep dermal 4-0 PDS followed by running subcuticular 4-0 Monocryl closure. The patient had Dermabond and then a surgical bra placed over dry sterile gauze at the end of the case. There were no intraoperative conditions.
Second Patient:
PREOPERATIVE DIAGNOSIS: Breast cancer, status post bilateral mastectomies and
reconstruction with tissue expanders and left sentinel lymph node. Those
surgeries were completed on, and the patient presents for
exchange of her expanders.
POSTOPERATIVE DIAGNOSIS: Breast cancer, status post bilateral mastectomies
and reconstruction with tissue expanders and left sentinel lymph node. Those
surgeries were completed on, and the patient presents for
exchange of her expanders.
PROCEDURE:
1. Removal of the tissue expanders.
2. Placement of permanent silicone implants.
3. Complex closure 4.5 cm from the trunk.
ESCRIPTION OF PROCEDURE: After informed was obtained, the patient was taken
to the operating room. A time-out was performed. She was given a
prophylactic dose of antibiotics. She was placed in sequential compression
devices prior to induction of anesthesia. The chest wall was prepped and
draped in routine sterile fashion. The existing incisions were marked out.
The patient had 350 mL of saline in the tissue expanders at the beginning of
the case. The expanders were inflated to 425 g and then the incisions were injected
with local anesthesia. The incisions were made sharply full thickness through
skin and subcutaneous tissue. Approximately 6 cm incisions were used on each side, based on the existing mastectomy scars. The capsule was entered and then the tissue
expander was removed from the surrounding area and passed off the field. The capsules were evaluated. They appear to be in good position. They were copiously irrigated with saline, followed by triple antibiotic solution. The decision was made to put a 425 cc smooth, round silicone breast implant in each pocket. This was done after washing and irrigating with triple antibiotic solution and then placing the implant using a no-touch technique. The left breast implant is reference #20-425, serial
#16847338 Natrelle silicone filled breast implant, style 20. On the right
side, reference #20-425, serial #16702771 Natrelle silicone filled breast
implant, style 20, volume 425 cc. Once that was done, the incisions were
closed with deep dermal 4-0 PDS and then running subcuticular closure. There
were dog ears on the incisions. A total of 4.5 cm of dog ear excision and closures were performed. The removed tissue was sent as pathology specimen. The incisions
were closed with deep dermal interrupted 4-0 PDS, followed by a running closure as
well as interrupted 5-0 fast-absorbing plain gut closure. Dry gauze dressings and a surgical bra were placed. The patient tolerated the procedure well. The nipple reconstructions were deferred to a later date. She was awoken in the operating room and taken to the recovery room in stable condition.
No complications.
JodiPlease see the following:
First Patient:
PREOPERATIVE DIAGNOSIS: Breast cancer.
POSTOPERATIVE DIAGNOSIS: Breast cancer.
PROCEDURE: Removal of tissue expanders - bilaterally. Placement of silicone implants
bilaterally. Complex Closure 7cm.
OPERATIVE FINDINGS: This patient had a Natrelle silicone filled breast
implant placed in the left breast, reference #20-450, serial #17047531. The
volume was 450 cc, that was on the left side. On the right side, the patient
had a Natrelle 450 cc silicone implant placed which was reference #20-450,
serial #17194729, that was on the right breast.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient
was taken to the operating room. A time-out was performed in which the
patient's name, medical record number, date of birth, site and side of
operation were confirmed and agreed upon by all present. A prophylactic dose
of Kefzol was given prior to incision. The patient had sequential compression
devices on her calves prior to the induction of the anesthesia. The chest
wall was prepped and draped in the routine sterile fashion. The existing
incisions were marked out and then a 6 cm incision at the existing scar
was created sharply on each side after using 1% lidocaine with epinephrine in a field block. The capsule was encountered, entered and the expanders were removed. Saline irrigation was performed and then sizers were used to confirm a volume of 450 cc on each side. The areas were copiously irrigated with triple antibiotic solution and
then silicone implants were brought up to the field. Dog ear excisions were marked out along the breast skin bilaterally. The total length of excess skin excision was 7cm. The dog ears consisting of skin and subcutaneous tissue were sharply excised using a 15 blade. These were passed off as pathology specimens from the left and right breast. The resultant defects were then closed in layers, deep dermals followed by running subcuticular closure. The breast implant access incisions also were closed in layers, deep dermal 4-0 PDS followed by running subcuticular 4-0 Monocryl closure. The patient had Dermabond and then a surgical bra placed over dry sterile gauze at the end of the case. There were no intraoperative conditions.
Second Patient:
PREOPERATIVE DIAGNOSIS: Breast cancer, status post bilateral mastectomies and
reconstruction with tissue expanders and left sentinel lymph node. Those
surgeries were completed on, and the patient presents for
exchange of her expanders.
POSTOPERATIVE DIAGNOSIS: Breast cancer, status post bilateral mastectomies
and reconstruction with tissue expanders and left sentinel lymph node. Those
surgeries were completed on, and the patient presents for
exchange of her expanders.
PROCEDURE:
1. Removal of the tissue expanders.
2. Placement of permanent silicone implants.
3. Complex closure 4.5 cm from the trunk.
ESCRIPTION OF PROCEDURE: After informed was obtained, the patient was taken
to the operating room. A time-out was performed. She was given a
prophylactic dose of antibiotics. She was placed in sequential compression
devices prior to induction of anesthesia. The chest wall was prepped and
draped in routine sterile fashion. The existing incisions were marked out.
The patient had 350 mL of saline in the tissue expanders at the beginning of
the case. The expanders were inflated to 425 g and then the incisions were injected
with local anesthesia. The incisions were made sharply full thickness through
skin and subcutaneous tissue. Approximately 6 cm incisions were used on each side, based on the existing mastectomy scars. The capsule was entered and then the tissue
expander was removed from the surrounding area and passed off the field. The capsules were evaluated. They appear to be in good position. They were copiously irrigated with saline, followed by triple antibiotic solution. The decision was made to put a 425 cc smooth, round silicone breast implant in each pocket. This was done after washing and irrigating with triple antibiotic solution and then placing the implant using a no-touch technique. The left breast implant is reference #20-425, serial
#16847338 Natrelle silicone filled breast implant, style 20. On the right
side, reference #20-425, serial #16702771 Natrelle silicone filled breast
implant, style 20, volume 425 cc. Once that was done, the incisions were
closed with deep dermal 4-0 PDS and then running subcuticular closure. There
were dog ears on the incisions. A total of 4.5 cm of dog ear excision and closures were performed. The removed tissue was sent as pathology specimen. The incisions
were closed with deep dermal interrupted 4-0 PDS, followed by a running closure as
well as interrupted 5-0 fast-absorbing plain gut closure. Dry gauze dressings and a surgical bra were placed. The patient tolerated the procedure well. The nipple reconstructions were deferred to a later date. She was awoken in the operating room and taken to the recovery room in stable condition.
No complications.
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