I am new to coding for general surgery and have a question. I am working on a chart where pt had a breast bx and am wondering if the layered (intermediate) closure is included in CPT 19125. The OP note is below.
Thank you,
Preop Diagnosis: BI-RADS 4 left breast lesion
Postop diagnosis: Same
Procedure: Left breast excisional biopsy
Surgeon: Couch
Anesthesia: General
EBL: 5 mL
Complications: None
Specimen: Left breast tissue to contain an RF ID marker
Details: This is a 68-year-old female with an abnormal mammogram with a lesion read as BI-RADS 4. It was not amenable to core needle biopsy and she is consented for an excisional biopsy. She was taken to the OR, positioned supine, prepped and draped. A time-out was performed. I then localized the RFID marker and made an incision directly over the marker. The tissue containing the RFID marker was then circumferentially excised down to the chest wall. Deep tissues were then closed with 3-0 Vicryl. Skin was run closed with a 4-0 Monocryl. The wound was dressed and the patient was taken to recovery.
Thank you,
Preop Diagnosis: BI-RADS 4 left breast lesion
Postop diagnosis: Same
Procedure: Left breast excisional biopsy
Surgeon: Couch
Anesthesia: General
EBL: 5 mL
Complications: None
Specimen: Left breast tissue to contain an RF ID marker
Details: This is a 68-year-old female with an abnormal mammogram with a lesion read as BI-RADS 4. It was not amenable to core needle biopsy and she is consented for an excisional biopsy. She was taken to the OR, positioned supine, prepped and draped. A time-out was performed. I then localized the RFID marker and made an incision directly over the marker. The tissue containing the RFID marker was then circumferentially excised down to the chest wall. Deep tissues were then closed with 3-0 Vicryl. Skin was run closed with a 4-0 Monocryl. The wound was dressed and the patient was taken to recovery.