Help With Breast surgery codes!!!!!

Coastal Coder

Salem, VA
Best answers
Good Morning,

I have a breast surgery note that I am stumped as to what to code. Any help would be greatly appreciated. THe patient has recurrent Left breast cancer after Mastectomy and implants placed. My Dr states she did a wide excision of recurrent cancer with sentinel node bx and excision of bilateral mastectomy scars and removal of intact implants.

She choose codes 19380,19328, and 38525, 38900. After reading the note I see 19307, ans 13100-13102(after I have her amend the note for measurements on the right). Would implant removal be bundled? Am I over analyzing this? HELP This is not something she has done since I have been here.

View attachment Michelle's Folder.pdf

Thanks in advance