mjfrog1
Guest
I would appreciate any help with providing a CPT code. This surgery was done by a different physician than who put in the original. I'll post the operative note.
THANK you for any assistance.
Sue, CPC, CCS-P
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PREOPERATIVE DIAGNOSIS: Malposition of MammoSite balloon.
POSTOPERATIVE DIAGNOSIS: Malposition of MammoSite balloon.
OPERATION PERFORMED: Repositioning of MammoSite balloon.
SUMMARY OF OPERATIVE PROCEDURE: On 04-03-12, the patient was administered intravenous sedation. She was subsequently prepped with Betadine solution. A sterile rubber glove was utilized to cover the distal portion of her MammoSite balloon. Local anesthetic of 1% Xylocaine was utilized. I then removed the old suture. I then opened up the wound and there was a small seroma which had nice clear fluid encountered. The spacer balloon had migrated a bit laterally and inferiorly. Basically what I did was I opened up one of the fingers of the glove. I was able to access the port and inflated the balloon. I was now able to draw the balloon back through the original tract and reposition it in the appropriate position. I then reinflated the balloon with 35cc of contrast and saline solution. I then reapproximated the subcutaneous tissue with 3-0 plain suture in a simple interrupted fashion. I closed the skin with a running subcuticular stitch of 3-0 Prolene. Prior to repositioning the balloon, I irrigated the cavity with normal saline. I irrigated the wound with normal saline. A dressing was applied.
The patient was then taken off the table and taken back to her room in satisfactory condition.
THANK you for any assistance.
Sue, CPC, CCS-P
#####################################
PREOPERATIVE DIAGNOSIS: Malposition of MammoSite balloon.
POSTOPERATIVE DIAGNOSIS: Malposition of MammoSite balloon.
OPERATION PERFORMED: Repositioning of MammoSite balloon.
SUMMARY OF OPERATIVE PROCEDURE: On 04-03-12, the patient was administered intravenous sedation. She was subsequently prepped with Betadine solution. A sterile rubber glove was utilized to cover the distal portion of her MammoSite balloon. Local anesthetic of 1% Xylocaine was utilized. I then removed the old suture. I then opened up the wound and there was a small seroma which had nice clear fluid encountered. The spacer balloon had migrated a bit laterally and inferiorly. Basically what I did was I opened up one of the fingers of the glove. I was able to access the port and inflated the balloon. I was now able to draw the balloon back through the original tract and reposition it in the appropriate position. I then reinflated the balloon with 35cc of contrast and saline solution. I then reapproximated the subcutaneous tissue with 3-0 plain suture in a simple interrupted fashion. I closed the skin with a running subcuticular stitch of 3-0 Prolene. Prior to repositioning the balloon, I irrigated the cavity with normal saline. I irrigated the wound with normal saline. A dressing was applied.
The patient was then taken off the table and taken back to her room in satisfactory condition.