How would you code Breast Lumpectomy and Sentinal LN Biopsy.
OP REPORT:
Approximately four different specimens were removed which resulted in removing nearly the entire axillary lymph node which included the majority of the axillary fat pad. We did identify the axillary vein, the latissimus dorsi, and the medial chest wall, and nearly all was removed consistent with an axillary lymph node dissection. We still were unable to identify and significant uptake of the radionuclide. At this point, we packed the wound and removed the breast lump by making an incision along the guidewire. It was carried down through the skin into the subcutaneous tissue using electrcautery for hemostasis. we then used sharp dissection to remove the entire area around the previous biopsy site. Electrocautery was then used to maintain hemostasis. we then sent this area off for pathologic exam. We then checked the axillary wound as well and closed the subcutaneous tissues. Again the majority of the axillary lymph node contents from both level 1 and level 2 nodes were removed although the needle probe failed to reveal any significant uptake of the radionuclide. All specimens were sent to pathology for exam.
Thanks for any help.
Stacey, CPC, CCA
OP REPORT:
Approximately four different specimens were removed which resulted in removing nearly the entire axillary lymph node which included the majority of the axillary fat pad. We did identify the axillary vein, the latissimus dorsi, and the medial chest wall, and nearly all was removed consistent with an axillary lymph node dissection. We still were unable to identify and significant uptake of the radionuclide. At this point, we packed the wound and removed the breast lump by making an incision along the guidewire. It was carried down through the skin into the subcutaneous tissue using electrcautery for hemostasis. we then used sharp dissection to remove the entire area around the previous biopsy site. Electrocautery was then used to maintain hemostasis. we then sent this area off for pathologic exam. We then checked the axillary wound as well and closed the subcutaneous tissues. Again the majority of the axillary lymph node contents from both level 1 and level 2 nodes were removed although the needle probe failed to reveal any significant uptake of the radionuclide. All specimens were sent to pathology for exam.
Thanks for any help.
Stacey, CPC, CCA
