sbrow043
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Please Help. I need help coding this central breast duct excision surgery. The physician is wanting to use 19112 & 11401. Coding wants to use 19120 & 19101. Which is correct?
DESCRIPTION OF THE PROCEDURE IN FULL:
Nipple skin biopsy was performed first. A small elliptical incision was planned to encompass the nodular abnormality on the nipple. Local anesthetic was injected and the incision was made and carried through the subcutaneous tissue with these electrocautery. The tissue was elevated and transected sharply and marked with a stitch at the aspect central to the nipple. Hemostasis was achieved and then the wound was closed in two layers with deep interrupted 3-0 Vicryl and simple interrupted 4-0 chromic sutures.
Preoperative image was reviewed personally by Dr.. Circumareolar incision was planned, and local anesthetic was injected and the incision was made and carried through the subcutaneous tissue with these electrocautery. A tissue plane was created approximately 5 mm deep to the nipple. This was carried across the entirety of the nipple and areola in order to transect the ductal system. The dissection was taken down circumferentially in order to take an approximate 3 x 3 cm sample and ensure that the ducts were fully transected. The specimen was removed. The Specimen was oriented in vivo prior to transection with 2 tails anteriorly, one short superior and one long lateral.
The wound was then irrigated and inspected for hemostasis. Excellent hemostasis was achieved with the use of electrocautery. The breast tissue was reapproximated with 3-0 PDS sutures. The wound was closed in layers with a deep 3-0 Vicryl suture, and a 4-0 Monocryl. Dermabond was placed over the wound, followed by Telfa and Tegaderm and a surgical bra.
Sponge and needle counts correct at the close of the procedure.
DESCRIPTION OF THE PROCEDURE IN FULL:
Nipple skin biopsy was performed first. A small elliptical incision was planned to encompass the nodular abnormality on the nipple. Local anesthetic was injected and the incision was made and carried through the subcutaneous tissue with these electrocautery. The tissue was elevated and transected sharply and marked with a stitch at the aspect central to the nipple. Hemostasis was achieved and then the wound was closed in two layers with deep interrupted 3-0 Vicryl and simple interrupted 4-0 chromic sutures.
Preoperative image was reviewed personally by Dr.. Circumareolar incision was planned, and local anesthetic was injected and the incision was made and carried through the subcutaneous tissue with these electrocautery. A tissue plane was created approximately 5 mm deep to the nipple. This was carried across the entirety of the nipple and areola in order to transect the ductal system. The dissection was taken down circumferentially in order to take an approximate 3 x 3 cm sample and ensure that the ducts were fully transected. The specimen was removed. The Specimen was oriented in vivo prior to transection with 2 tails anteriorly, one short superior and one long lateral.
The wound was then irrigated and inspected for hemostasis. Excellent hemostasis was achieved with the use of electrocautery. The breast tissue was reapproximated with 3-0 PDS sutures. The wound was closed in layers with a deep 3-0 Vicryl suture, and a 4-0 Monocryl. Dermabond was placed over the wound, followed by Telfa and Tegaderm and a surgical bra.
Sponge and needle counts correct at the close of the procedure.