Wiki Coding help needed

alg618

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Afton, VA
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How would you code this surgery? My provider selected 23078-22, 21558, 38745, 13121 and 13122 x 5.

The patient was brought to the operating room and placed on the OR table in the supine position. He was intubated and general endotracheal anesthesia was delivered. A Foley catheter was placed. The left shoulder and axilla and chest were prepped and draped in sterile fashion. A 30 cm long incision was made transversely across the left chest and then extending down into the axilla. We made the incision with the scalpel and continued dissection down through the subcutaneous tissues. We dissected down to the pectoralis major muscle. On imaging, the tumor could be seen bulging up into the pectoralis minor and major, and therefore I felt these were going to need to be partially excised in order to get access to the tumor and in order to get good margins wherever possible. We extended our dissection down into the incision down into the axilla. We then divided the pectoralis major tendon off of the humerus. We then dissected the attachments superiorly to the clavicle. We continued dissecting around the mass in the axilla. The mass was growing into the axillary lymph nodes and therefore a complete axillary lymph node dissection was needed to be performed in order to get adequate margins. There was a portion of the shoulder tumor that extended up cranial and ventral to the brachial plexus. This portion of the tumor was excised separately and was sent for permanent pathology. We continued dissecting the pectoralis major and minor en bloc with the tumor. The medial portion of the pectoralis major was then divided with the cautery and then the inferior portion was divided similarly with cautery so that the pectorals major and minor were left en bloc with the tumor. We then dissected the tumor off of the chest wall and off of the subscapularis muscle. The thoracodorsal vessels and nerve were involved with the tumor and these therefore were needed to be divided and ligated. We then turned our attention to dissecting the mass free from the axillary vein. We carefully dissected the mass off of the axillary vein. There were some larger vein branches draining the tumor going right into the axillary vein and these were tied and suture ligated. After we had the axillary vein dissected free from the mass, we then continued dissecting the mass free from the underside of the axillary artery and the entire brachial plexus. The mass extended deep to the brachial plexus and extended for quite some distance cranially. We continued dissecting the mass free from the surrounding structures. After we had completely excised the tumor, it was sent for permanent pathology. We inspected the wound and I felt that we had achieved a complete resection of the tumor. Bleeding was controlled with cautery and with ties and suture ligatures and clips. Throughout the dissection, lymphatic vessels were clipped with Hemoclips and divided with scissors. We then irrigated out the wound with sterile saline. In order to get the wound to close without tension, we created superior and inferior flaps with the cautery dissecting the subcutaneous tissue off of the chest wall. We then placed two #19-French round JP drains and sutured them to the skin with a #2-0 nylon suture. We then performed a complex repair of the shoulder wound after making our advancement flaps with the cautery. We placed a deep dermal layer of interrupted #3-0 Vicryls and then a second layer of interrupted #3-0 nylon vertical mattress sutures. The length of the incision was 30 cm. We then covered the wound with bacitracin ointment and sterile dressings and placed sterile dressings over the JP sites. We placed a JP bulb on both drains. All instrument, needle, and sponge counts were correct x2. The patient was extubated in the operating room and taken to the recovery room in stable condition.

Thanks in advance!
 
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