bostonmom
Networker
I am trying to code the following op note:
Op performed: implant exchange of the right breast capsulotomy and fat grafting.
Technique: there was a 325ml saline implant, electrocautery was used to perform a capsulotomy, the rest of the capsule opened. A 555cc implant was chosen, placed in the right breast with good symmetry to the left breast. Attention was then drawn to the abdomen, stab incisions were made at the anterior superior iliac crest, at the umbilicus, midaxillary line at the mid abdomen. Tumescent solution was then placed. Liposuction was then performed through various openings of the abdominal wall, the hips, the flanks and the thighs. This gathered up 300ml of usable fat graft, which was injected in the right breast in the superior pole, and some in the medial. Liposuction incisions were then closed with deep dermal suture and skin closed.
Patient previously had a masectomy with reconstruction done in 2004. The left breast has continued to grow while the right breast is way too small.
These are the codes that I have picked: 19340(immediate insertion of breast implant), 19380(revision of reconstructed breast), 11954(injection of the fat into the breast), 15877(liposuction of the trunk), 15879(liposuction of the lower extremities)
Diagnosis code: N65.0......I was not going to mention about the history of cancer since the surgeon did not mention it in the op notes, the surgeon only mentioned previous breast reconstruction in 2004
Can anyone offer any help or insight?
Op performed: implant exchange of the right breast capsulotomy and fat grafting.
Technique: there was a 325ml saline implant, electrocautery was used to perform a capsulotomy, the rest of the capsule opened. A 555cc implant was chosen, placed in the right breast with good symmetry to the left breast. Attention was then drawn to the abdomen, stab incisions were made at the anterior superior iliac crest, at the umbilicus, midaxillary line at the mid abdomen. Tumescent solution was then placed. Liposuction was then performed through various openings of the abdominal wall, the hips, the flanks and the thighs. This gathered up 300ml of usable fat graft, which was injected in the right breast in the superior pole, and some in the medial. Liposuction incisions were then closed with deep dermal suture and skin closed.
Patient previously had a masectomy with reconstruction done in 2004. The left breast has continued to grow while the right breast is way too small.
These are the codes that I have picked: 19340(immediate insertion of breast implant), 19380(revision of reconstructed breast), 11954(injection of the fat into the breast), 15877(liposuction of the trunk), 15879(liposuction of the lower extremities)
Diagnosis code: N65.0......I was not going to mention about the history of cancer since the surgeon did not mention it in the op notes, the surgeon only mentioned previous breast reconstruction in 2004
Can anyone offer any help or insight?