codedog
True Blue
I was told to code this as 19301, 38525, 19125 , not sure because I dont see any margins issue . Am I missing something ?
PREOPERATIVE DIAGNOSIS: Right breast cancer, high-grade DCIS.
POSTOPERATIVE DIAGNOSIS: Right breast cancer, high-grade DCIS.
PROCEDURES PERFORMED: Right breast lumpectomy with needle localization and sentinel node biopsy.
DESCRIPTION OF THE PROCEDURE: Consents were obtained from the patient previous to surgery. The patient did have needle localization as well as radiographic injections to the sentinel node prior to operation.
OPERATIVE FINDINGS: The patient was brought to the operating theater. was prepped and draped in a sterile fashion. 1 g of Ancef was given prior to skin incision. Attention was first made towards the sentinel node. Isoflurane blue was injected into the areolar area of previous incision. Radiographically, the active node was found on the skin and through the skin an incision was made there. Lymph node was dissected out using electrocautery and sent for frozen. Frozen did come back as negative for malignancy. Then attention was made towards the right breast lumpectomy. Two wires were inserted at the previous surgery, the anterior wire was at area of suspicion for ultrasound and the posterior wire was in the microcalcification. Each specimen was dissected out using a Harmonic scalpel, was sent for evaluation. Hemostasis was excellent. The incisions were then closed with a 3-0 Vicryl deep dermal sutures as well as 3-0 Vicryl subcuticular running. Steri-Strips were applied. The patient did tolerate the procedure well. There were no complications. All counts were correct x2.
PREOPERATIVE DIAGNOSIS: Right breast cancer, high-grade DCIS.
POSTOPERATIVE DIAGNOSIS: Right breast cancer, high-grade DCIS.
PROCEDURES PERFORMED: Right breast lumpectomy with needle localization and sentinel node biopsy.
DESCRIPTION OF THE PROCEDURE: Consents were obtained from the patient previous to surgery. The patient did have needle localization as well as radiographic injections to the sentinel node prior to operation.
OPERATIVE FINDINGS: The patient was brought to the operating theater. was prepped and draped in a sterile fashion. 1 g of Ancef was given prior to skin incision. Attention was first made towards the sentinel node. Isoflurane blue was injected into the areolar area of previous incision. Radiographically, the active node was found on the skin and through the skin an incision was made there. Lymph node was dissected out using electrocautery and sent for frozen. Frozen did come back as negative for malignancy. Then attention was made towards the right breast lumpectomy. Two wires were inserted at the previous surgery, the anterior wire was at area of suspicion for ultrasound and the posterior wire was in the microcalcification. Each specimen was dissected out using a Harmonic scalpel, was sent for evaluation. Hemostasis was excellent. The incisions were then closed with a 3-0 Vicryl deep dermal sutures as well as 3-0 Vicryl subcuticular running. Steri-Strips were applied. The patient did tolerate the procedure well. There were no complications. All counts were correct x2.