Wiki I&D axillary abscess---removal of axillary mass


Perryville, MO
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I have two axillary procedures that I am having a difficult time with. I've researched the forum and found threads stating axilla falls under thorax. I've attached the notes and would appreciate feedback.

Procedure 1: I&D, packing axillary abscess
Abscess was parallel to the axillary crease slightly on the chest wall side. Incision was made along the axis of the abscess with a 2 cm incision through skin into the purulent tissue.The entire abscess cavity was opened. Wide drainage was performed by resecting about 3 mm segments of skin from the proximal and distal edges of the initial skin incision. The underlying wound was widely opened. There was some thickening of the skin and a small ruptured cyst could not be ruled out. The wound was irrigated and packed with quarter inch Nu-gauze and a sterile dressing. I was looking at 21501 ?

Procedure 2: removal of axillary mass
1% lidocaine with epinephrine was used for local anesthesia and a 3 cm. transverse incision was made in the right axilla and carried to the subcutaneous tissue with sharp dissection down to this axillary mass. It had characteristics of ectopic breast tissue approximately 3 cm. segment of mass. Tissue was excised and submitted for pathological evaluation. Hemostasis was achieved with 3-0 silk ties and electrocautery. Copious irrigation with water was done then closure was done in 2 layers using 3-0 Dexon to approximate the subcutaneous tissue and skin was closed with subcuticular placed interrupted 3-0 Vicryl. Steri-strips, telfa and bioclusive dressings were applied and a bulky dressing was placed in the axilla. I was looking at 21552 ?
I&D / Excision Mass

Proc. 1 is an I&D - CPT 10061. I don't see evidence of doing deep into fascia or muscle.

Proc 2 looks like you have it right with 21552.

Hope that helps.

F Tessa Bartels, CPC, CEMC