Help with coding resection
LEFT BREAST REPEAT LUMPECTOMY
LEFT CHEST WALL RESECTION Operative Note
Patient A
2/6/2017
Pre-op Diagnosis: Recurrent L breast cancer
Post-op Diagnosis: Post-Op Diagnosis Codes:
Malignant neoplasm of upper-inner quadrant of left female breast
Procedure: Procedure(s):
LEFT BREAST REPEAT LUMPECTOMY
LEFT CHEST WALL RESECTION
Surgeon: Doctor A - Primary
Assistants: Doctor B - Assisting
Anesthesia Staff: Anesthesiologist: Doctor C
Anesthesia Type: General
ASA Class: II
Indications: Recurr breast ca
Procedure Details: After the breast was sterilely preppped and draped, a timeout was performed. With Dr. B in attendance, an ellipse of skin was marked and then excised approximately 4cmx2cm. This was carried to the subQ and followed a little further lateral to the fascia which was incised circumferentially. I then took the muscle just deep to the fascia to complete the resection. The implant was not exposed. There was muscle covering it and Dr. B felt no further coverage was necessary. There was a good 5-6cm of fascial defect after the resection. The specimen was oriented and sent to pathology. The skin was closed with interrupted 3-0 Polysorbs and skin glue. She tol well. Some marcaine was instilled into the skin before closure.
I know I would code 19301 is there a second code for the recession or is it included.
LEFT BREAST REPEAT LUMPECTOMY
LEFT CHEST WALL RESECTION Operative Note
Patient A
2/6/2017
Pre-op Diagnosis: Recurrent L breast cancer
Post-op Diagnosis: Post-Op Diagnosis Codes:
Malignant neoplasm of upper-inner quadrant of left female breast
Procedure: Procedure(s):
LEFT BREAST REPEAT LUMPECTOMY
LEFT CHEST WALL RESECTION
Surgeon: Doctor A - Primary
Assistants: Doctor B - Assisting
Anesthesia Staff: Anesthesiologist: Doctor C
Anesthesia Type: General
ASA Class: II
Indications: Recurr breast ca
Procedure Details: After the breast was sterilely preppped and draped, a timeout was performed. With Dr. B in attendance, an ellipse of skin was marked and then excised approximately 4cmx2cm. This was carried to the subQ and followed a little further lateral to the fascia which was incised circumferentially. I then took the muscle just deep to the fascia to complete the resection. The implant was not exposed. There was muscle covering it and Dr. B felt no further coverage was necessary. There was a good 5-6cm of fascial defect after the resection. The specimen was oriented and sent to pathology. The skin was closed with interrupted 3-0 Polysorbs and skin glue. She tol well. Some marcaine was instilled into the skin before closure.
I know I would code 19301 is there a second code for the recession or is it included.