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Wiki Chest Wall Mass Removal

tch678

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Santa Clara, CA
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I am trying to get the correct CPT code for the attached surgery. The office gave me 21601 and I don't believe that is correct because no bone was removed. Can someone please help?

Post- Procedure Diagnosis: Post-Op Diagnosis Codes:
* Ductal carcinoma of right breast [C50.911]
Procedures performed and description: Procedure(s):
CHEST WALL RESECTION 3x 6 cm

Findings: nodule in the chest wall right side incision

Indications: had invasive ductal ca s/p mastectomy right with a small local recurrence in the incision along the chest wall. Risks of bleeding, infection, anesthesia explained.

Details of Procedure: Once informed consent was obtained the patient was brought to the OR and placed on the OR table. A safety briefing was performed and the patient was intubated. The patient was prepped and draped in standard surgical fashion, and a time out was performed. The nodule was identified preoperatively and marked. An ellipse was marked over the area of the nodule measuring 6 x 3 cm. It was incised and carried down to the chest wall. It was marked an passed off the field. The wound was then closed in two layers with 3-0 and 4-0 vicryl. All sponge and needle counts were correct at the end of the case.
 
Hi
Id use CPT 11606 size fits & malignant lesion in chest area since it seems on right side chest incision where her breast surgery done already. I hope this helps you.I did look at CPT 19301 but that is for breast mastectomy.
Hope this data helps you
Lady T
 
I usually code these as soft tissue tumor excisions (21552/21555-21556/21554) but the documentation needs to state if it was in the subq or muscle/fascia.
 
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