Hi, hoping some of you Plastic Surgery coders can weigh in on this one for me. Struggling with what CPT codes to bill for this procedure:
INDICATIONS: The patient is a 59-year-old woman who had previously undergone bilateral mastectomies for breast carcinoma. Redundant skin was left to allow for a reconstruction; however, the patient has elected not to undergo reconstruction. She has a significant amount of redundant skin at the medial aspect of the right mastectomy site which creates constant irritation as it is compressed by her clothing. The area excised measured 9 x 4 cm. On the left side, there was significantly more redundant skin with a chronic skin rash in the area where the skin folded upon itself. The area of skin excised on the left side measured 23 x 5 cm.
OPERATIVE TECHNIQUE: The patient was marked preoperatively while in the upright position in the preoperative holding area and then taken to the operating room and placed on the operating table in the supine position. After the administration of general anesthesia, the full chest was prepped with Chloraprep and draped in the usual sterile fashion.
Beginning on the right side, the lenticular incision was made as per the preoperative markings. Dissection was carried down to the deep subcutaneous plane and then the skin and adipose tissue were excised and sent for pathology. Because the surrounding skin was significantly tethered to the underlying pectoralis major muscle, adding to the deformity, the skin was now undermined using electrocautery to allow closure with less distortion and less tension and this allowed a much better leveling of the skin, creating a normal smooth contour. Closure was now performed in multiple layers with 3-0 Vicryl in the fascia and deep dermis to close up any dead space and then the skin was closed with running 4-0 Vicryl subcuticular sutures. On the left side, the large lenticular incision was made and again dissection was carried down to the pectoralis major muscle using electrocautery and the redundant skin and adipose tissue were excised. Again, to allow closure without distortion and without tension, the superior and inferior mastectomy flaps were mobilized with electrocautery several centimeters superiorly and inferiorly. Hemostasis was obtained with electrocautery and the wounds were irrigated with sterile saline solution and then once again closure was performed in layers with 3-0 Vicryl in the fascia and deep dermis, followed by running 4-0 Vicryl subcuticular sutures. The wounds were cleaned and dried, and then Mastisol and Steri-Strips were placed, followed by sterile dressings.
The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Estimated blood loss was less than 20 mL.
Thanks in advance for your help!
INDICATIONS: The patient is a 59-year-old woman who had previously undergone bilateral mastectomies for breast carcinoma. Redundant skin was left to allow for a reconstruction; however, the patient has elected not to undergo reconstruction. She has a significant amount of redundant skin at the medial aspect of the right mastectomy site which creates constant irritation as it is compressed by her clothing. The area excised measured 9 x 4 cm. On the left side, there was significantly more redundant skin with a chronic skin rash in the area where the skin folded upon itself. The area of skin excised on the left side measured 23 x 5 cm.
OPERATIVE TECHNIQUE: The patient was marked preoperatively while in the upright position in the preoperative holding area and then taken to the operating room and placed on the operating table in the supine position. After the administration of general anesthesia, the full chest was prepped with Chloraprep and draped in the usual sterile fashion.
Beginning on the right side, the lenticular incision was made as per the preoperative markings. Dissection was carried down to the deep subcutaneous plane and then the skin and adipose tissue were excised and sent for pathology. Because the surrounding skin was significantly tethered to the underlying pectoralis major muscle, adding to the deformity, the skin was now undermined using electrocautery to allow closure with less distortion and less tension and this allowed a much better leveling of the skin, creating a normal smooth contour. Closure was now performed in multiple layers with 3-0 Vicryl in the fascia and deep dermis to close up any dead space and then the skin was closed with running 4-0 Vicryl subcuticular sutures. On the left side, the large lenticular incision was made and again dissection was carried down to the pectoralis major muscle using electrocautery and the redundant skin and adipose tissue were excised. Again, to allow closure without distortion and without tension, the superior and inferior mastectomy flaps were mobilized with electrocautery several centimeters superiorly and inferiorly. Hemostasis was obtained with electrocautery and the wounds were irrigated with sterile saline solution and then once again closure was performed in layers with 3-0 Vicryl in the fascia and deep dermis, followed by running 4-0 Vicryl subcuticular sutures. The wounds were cleaned and dried, and then Mastisol and Steri-Strips were placed, followed by sterile dressings.
The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Estimated blood loss was less than 20 mL.
Thanks in advance for your help!