Wiki Capsulectomy no implant

daniel

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I’m looking at CPT 13101-13102, but I’m stumped on the capsulectomy with no implant removal. Would we just use CPT 19371 with modifier 52 by itself.

Or CPT 19371 + 13101.59 +13102.59

Scrubbed note


OPERATION PERFORMED:
1. Scar revision of the right chest wall from previous mastectomy and previous breast reconstruction scar closed in layered fashion with a final closure length of 11 cm.
2. Complete capsulectomy of the right chest wall from previous placement of an old tissue expander and implant.



INDICATION FOR PROCEDURE: patient who had a diagnosis of breast cancer several years ago and elected to have bilateral mastectomies and immediate reconstruction with tissue expander and implants. The cancer was on the right side and she had radiation, and on 2 different occasions her implant became infected and had to be removed, and she had a painful scar that was on the right side. She was not interested in any more reconstruction, but wanted to have the scar released because it was so painful. We agreed to do this and made arrangements for this to be carried out.

OPERATIVE REPORT: Patient was marked in the preop holding area, taken to the operating room, and placed under general anesthetic with all of the appropriate monitoring. Once this was done, the patient's scar was marked and the right chest wall area was stabbed with a #15 blade and the area was infused with tumescent fluid for approximately 100 cc of tumescent fluid. Once this was done, the scar itself was excised and passed off for pathology, and then once the scar was excised, the scar widened and we immediately saw that we had an old breast capsule that was serous in nature and needed to be completely removed in order to allow the tissues to scarred out. Once this was done, the capsule was carefully removed with the electrocautery, and it was a complete capsulectomy, including on the chest wall and ribs. Once this was done, the area was injected, was checked for bleeding and hemostasis was controlled with electrocautery. The pocket was then washed of excess solution with saline. Hemostasis was corrected with the electrocautery. A #15 round trocar drain was placed through a lateral stab wound and sutured to the chest wall with 2-0 silk, and then the wound was closed with deep sutures of 2-0 Vicryl and then a subcuticular 3-0 Monocryl. Once this was done, the chest was washed of excess prep solution and dried. Dermabond was applied to the wound, as well as Steri-Strips. The drain had been sewn into place with a 2-0 silk. A Biopatch was placed around it, along with Tegaderms. Patient was then placed in fluffs and a chest binder. tolerate the procedure without difficulty, and was allowed to be awakened, extubated, and transported to the recovery room,
 
19371- capsulectomy included old implant removal (if the implant is ruptured, code with 19330). Check if you will get NCCI edit by coding 19371 and scar revision. If it does, scar revision with 59 or XU depends on your facility's protocol .
 
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