Breast surgery repair

garcia06

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Can you please help to code the repair of breast surgery

19301 RT and should it be a complex repair 13101 ?

The patient was marked in the preoperative holding area, consents were confirmed, and she was brought back to the operating room and positioned supine on the operating table. SCDs were placed on her lower extremities. Antibiotics were administered, and general LMA anesthesia was induced.
After a sterile prep and drape of the right breast, local anesthesia was infiltrated in the skin and subcutaneous tissues. Next an elliptical incision was made in the 10 o'clock position around the mass and the area tethered to the skin. The dissection was carried into the deeper breast tissues to the palpable mass. A partial mastectomy was performed around the mass using palpation as a guide. The dissection aimed for 05.-1cm margins. The specimen was amputated from the breast, oriented with marking inks. Specimen was sent for permanent pathology.Hemostasis was achieved with electrocautery. Clips were placed for future reference. The cavity was irrigated with saline. The deeper tissues were freed up from the surrrounding breast tissue into flaps. The flaps were re approximated over a 7cm by 3cm area to close the defect. These were approximated with 2-0 vicryl. An additional skin "dog ear" was excised inferior-medially to improve the cosmesis. The skin was closed in multiple layers including 3-0 in the deep subcutaneous tissue, 3-0 vicryl in the deep dermis and 4-0 monocryl in the subcuticular layer. Dermabond was placed on the closed incision. The needle sponge instrument counts were correct x2. The patient was awakened in the operating room and taken to the PACU in stable condition

Thank you,
garcia06
 

haraml7

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Hello,

It looks like the surgeon actually performed a reconstructive procedure for the breast by performing the "dog ear" approach. The additional skin was excised inferior-medially to improve the cosmesis. I would suggest using 19380 in addition to your 19301. NCCI edits are showing no edits for these 2 codes.

The procedure 19380 includes a layered closure.

Let me know if you have any other questions i will be happy to help.
 
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