codedog
True Blue
i say this this report should be coded as 19125 ,my boss wants me to code it as 19301. I know 19301 has something to do with the margins , but I dont see where it isin report, does any see where this can be 19301, it so please tell me why -thanks , 19125 seems right to me.- o by the way path report came back as infiltrating ductal carcinoma - had a note on it that read - carcinoma is present at inked margin of excision
POSTOPERATIVE DIAGNOSIS: Left breast mass.
OPERATION: Left needle localization breast biopsy with specimen around 5 cm circumscribed.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, and underwent general anesthesia with successful endotracheal intubation. The patient was examined by me in the preoperative holding area and gone to Radiology and had a left needle placed via mammography. The covering was removed. The wire was kept in place and left breast was prepped and draped in normal fashion. The patient had received preoperative antibiotics prior to skin incision. An incision over the wire including the mastectomy incision was made for around 5 to 6 cm. Dissection was carried down through the skin and subcutaneous tissue. The entire wire with surrounding tissues for around 4 to 5 cm was removed with the entire wire. This was done with Bovie cauterization. Specimen was removed and sent to Radiology, and they confirmed that we did have the area of interest, that it was not in the patient and was in the specimen that was removed. After getting confirmation that we successfully removed the specimen via needle localization, the wound was irrigated. There was noted to be excellent hemostasis. Subdermals were closed with 3-0 Vicryl interrupted and subcuticular closed with 4-0 Vicryl running in a subcuticular fashion. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS: Left breast mass.
OPERATION: Left needle localization breast biopsy with specimen around 5 cm circumscribed.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, and underwent general anesthesia with successful endotracheal intubation. The patient was examined by me in the preoperative holding area and gone to Radiology and had a left needle placed via mammography. The covering was removed. The wire was kept in place and left breast was prepped and draped in normal fashion. The patient had received preoperative antibiotics prior to skin incision. An incision over the wire including the mastectomy incision was made for around 5 to 6 cm. Dissection was carried down through the skin and subcutaneous tissue. The entire wire with surrounding tissues for around 4 to 5 cm was removed with the entire wire. This was done with Bovie cauterization. Specimen was removed and sent to Radiology, and they confirmed that we did have the area of interest, that it was not in the patient and was in the specimen that was removed. After getting confirmation that we successfully removed the specimen via needle localization, the wound was irrigated. There was noted to be excellent hemostasis. Subdermals were closed with 3-0 Vicryl interrupted and subcuticular closed with 4-0 Vicryl running in a subcuticular fashion. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
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