Wiki Any help with coding this procedure would be appreciated.

[rlsanch2005@gmail.com]

PROCEDURE PERFORMED: Right axillary exploration and capsulectomy.

OPERATIVE FINDINGS: The patient had a well-defined seroma capsule extending
from the lateral border of the pectoralis along the chest wall and up into
the apex of the axilla.

DETAILS OF PROCEDURE: Informed consent was obtained. The patient was taken to
the operating room, placed on the table in the supine position. She
underwent a general anesthetic. Her left arm, axilla and chest wall were
sterilely prepped and draped and her current drain was left in place. The
lateral portion of her mastectomy incision was incised. This was extended
further laterally. Dissection was then carried up to the drain that was in
place, which was followed down to the seroma cavity, which was opened. There
was a well defined capsule along the lateral border of the pectoralis, the
chest wall and extending up into the apex of the axilla. No obvious open
lymphatics were identified. The seroma capsule was gradually excised. Linear
structures encountered were clipped as needed. At the apex of the axilla and
against the chest wall the capsule was densely adherent and the remaining
surface of the capsule was cauterized. The wound was irrigated and examined
for lymphatic leakage. No leakage was appreciated. A medium JP drain was
placed via a separate incision and placed in the area of the dissection. It
was secured to the skin with 3-0 nylon. Skin was then closed with
interrupted 3-0 Vicryl and running 4-0 Monocryl and Steri-Strips and a
sterile dressing were applied. The old drain was removed in the course of
the procedure.


Thank you in advance for any suggestions.

 

[efredette]

Right axillary exploration and capsulectomy

From the op note it sounds like it would be coded as 19371-RT.

19371
Periprosthetic capsulectomy, breast

Lay Description

The physician performs a periprosthetic capsulectomy on the breast. An incision in the skin of the breast at the site of a mastectomy scar, in the skin fold beneath the breast, or around the nipple is made. The physician uses a cautery knife to cut into the area of fibrous scarring associated with a breast implant. The contracted capsule is excised from the breast tissue and the prosthesis is removed. The incision is repaired with layered closure.

Coding Tips

This is a unilateral procedure. If performed bilaterally, some payers require that the service be reported twice with modifier 50 appended to the second code while others require identification of the service only once with modifier 50 appended. Check with individual payers. Modifier 50 identifies a procedure performed identically on the opposite side of the body (mirror image). For breast capsulotomy, see 19370. Supplies used when providing this procedure may be reported with A4461 and A4463. Check with the specific payer to determine coverage.