Can anyone guide me in the direction of the right code? I feel like it's missing documentation. My vote was 19303-RT, 38500, 38900
Procedure:
1. Right simple mastectomy
2. Right axillary sentinel lymph node biopsy
3. Injection of blue dye for sentinel node identification
4. intermediate closure 12 cm length
...2cc of methylene blue were injected into the retroareolar dermis and the breast was massaged for five minutes. An elliptical incision was made encompassing the nipple-areolar complex. The flaps were elevated superiorly to the clavicle, medially to the boarder of the sternum, and inferiorly to the infamammary crease, laterally to the surface of the axillary space was exposed, a needle probe was used to guide dissection efforts and blue stained hot sentinel node was excised. The ex-vivo 10-second count was 25000. Backround count was 685, so the sentinel node dissection was complete. This was sent to path. The remainder of the pectoral fascial attachments were amputated. A 10 flat JP drain was placed over the pectoral fascia and then an intermediate closure was performed 12cm in length...After completion of the mastectomy and examination of the specimen, some puckering of the pectoral fascia was visible beneath the tumor. Because of the concern of possible positive margin there, a portion of the pectoral muscle was excised for re-excision of the deep margin and this was labeled as such and submitted to path.
Procedure:
1. Right simple mastectomy
2. Right axillary sentinel lymph node biopsy
3. Injection of blue dye for sentinel node identification
4. intermediate closure 12 cm length
...2cc of methylene blue were injected into the retroareolar dermis and the breast was massaged for five minutes. An elliptical incision was made encompassing the nipple-areolar complex. The flaps were elevated superiorly to the clavicle, medially to the boarder of the sternum, and inferiorly to the infamammary crease, laterally to the surface of the axillary space was exposed, a needle probe was used to guide dissection efforts and blue stained hot sentinel node was excised. The ex-vivo 10-second count was 25000. Backround count was 685, so the sentinel node dissection was complete. This was sent to path. The remainder of the pectoral fascial attachments were amputated. A 10 flat JP drain was placed over the pectoral fascia and then an intermediate closure was performed 12cm in length...After completion of the mastectomy and examination of the specimen, some puckering of the pectoral fascia was visible beneath the tumor. Because of the concern of possible positive margin there, a portion of the pectoral muscle was excised for re-excision of the deep margin and this was labeled as such and submitted to path.
