cpccoder2008
True Blue
SURGERY PERFORMED:
1. Wire-directed segmental resection, upper central segment, left breast.
2. Isosulfan blue dye injection for sentinel lymph node mapping, left breast.
3. Sentinel lymph node dissection, left axilla.
4. Ultrasound localization of guidewires, underlying tumor and measurement of balloon to skin distance during intraoperative radiotherapy.
5. Balloon insertion for intraoperative radiation therapy (IORT).
DESCRIPTION OF THE OPERATIVE PROCEDURE:
In the Operating Room, she was prepped and draped with her arms extended. Five tenths of 1mL of isosulfan blue dye was injected in the upper outer quadrant of the right breast for sentinel lymph node mapping. Sentinel lymph node dissection was done first.
A small transverse incision was made in the lower axilla, was carried down through fat and fascia and the axilla entered. Blue lymphatic was easily found, which led to a cluster of blue and hot lymph nodes. These nodes were removed and they had anywhere between 150 and 350 counts. They were frozen, all were reported back as being negative. The axilla was carefully visually and digitally examined. There were no other hot nodes, no blue nodes, no palpable nodes and no additional nodes removed.
At the conclusion of the procedure, the axilla was closed with 2-0 Vicryl on deep tissues, 3-0 Monocryl deep dermal tissues and a subcuticular 4-0 Monocryl suture followed by Dermabond.
Next, attention was turned to the breast. The upper central portion of the breast was anesthetized with local anesthesia.
Ultrasound was used to map out the wires' placement and direction. Full-thickness skin was incised using the previously drawn triangular shaped. Both superior wires were brought into the wound. All tissue around and between both wires was removed down to and including the pectoralis major muscle fascia.
Specimen was removed and color coated. Correct clips were used to orient the specimen. Specimen radiography was performed. I was able to remove another superior, inferior, medial and lateral margin. The deep margin had already been removed as the tissue was taken down to and including the pectoralis major muscle fascia.
The wound was irrigated copiously with saline. Meticulous hemostasis was obtained.
Intraoperative radiation therapy was then performed. A 7 cm stainless steel shireld was inserted to protect the chest wall. A series of #2 Ethilon suture was placed. The superior and inferior sutures were tied. It was deemed that a 3 to 4cm balloon with 30mL of saline would fill the space perfectly. Ultrasound was then used to make certain that the skin to balloon distance was 1cm or more in all directions.
At the conclusion of IORT, the Ethilon sutures were removed. The stainless steel shield which protected the chest wall was removed and the balloon was removed. Wound was irrigated copiously with saline.
Can someone please help me with this op report ? I haven't coded outpatient in awhile and I'm uncertain if my codes are correct. I came up with 38525, 19301, 19297 and 38792.
Thanks in advanced
1. Wire-directed segmental resection, upper central segment, left breast.
2. Isosulfan blue dye injection for sentinel lymph node mapping, left breast.
3. Sentinel lymph node dissection, left axilla.
4. Ultrasound localization of guidewires, underlying tumor and measurement of balloon to skin distance during intraoperative radiotherapy.
5. Balloon insertion for intraoperative radiation therapy (IORT).
DESCRIPTION OF THE OPERATIVE PROCEDURE:
In the Operating Room, she was prepped and draped with her arms extended. Five tenths of 1mL of isosulfan blue dye was injected in the upper outer quadrant of the right breast for sentinel lymph node mapping. Sentinel lymph node dissection was done first.
A small transverse incision was made in the lower axilla, was carried down through fat and fascia and the axilla entered. Blue lymphatic was easily found, which led to a cluster of blue and hot lymph nodes. These nodes were removed and they had anywhere between 150 and 350 counts. They were frozen, all were reported back as being negative. The axilla was carefully visually and digitally examined. There were no other hot nodes, no blue nodes, no palpable nodes and no additional nodes removed.
At the conclusion of the procedure, the axilla was closed with 2-0 Vicryl on deep tissues, 3-0 Monocryl deep dermal tissues and a subcuticular 4-0 Monocryl suture followed by Dermabond.
Next, attention was turned to the breast. The upper central portion of the breast was anesthetized with local anesthesia.
Ultrasound was used to map out the wires' placement and direction. Full-thickness skin was incised using the previously drawn triangular shaped. Both superior wires were brought into the wound. All tissue around and between both wires was removed down to and including the pectoralis major muscle fascia.
Specimen was removed and color coated. Correct clips were used to orient the specimen. Specimen radiography was performed. I was able to remove another superior, inferior, medial and lateral margin. The deep margin had already been removed as the tissue was taken down to and including the pectoralis major muscle fascia.
The wound was irrigated copiously with saline. Meticulous hemostasis was obtained.
Intraoperative radiation therapy was then performed. A 7 cm stainless steel shireld was inserted to protect the chest wall. A series of #2 Ethilon suture was placed. The superior and inferior sutures were tied. It was deemed that a 3 to 4cm balloon with 30mL of saline would fill the space perfectly. Ultrasound was then used to make certain that the skin to balloon distance was 1cm or more in all directions.
At the conclusion of IORT, the Ethilon sutures were removed. The stainless steel shield which protected the chest wall was removed and the balloon was removed. Wound was irrigated copiously with saline.
Can someone please help me with this op report ? I haven't coded outpatient in awhile and I'm uncertain if my codes are correct. I came up with 38525, 19301, 19297 and 38792.
Thanks in advanced