Stacey Walden
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We are looking for a code that adequately encompasses the surgery that was performed.
Patient presented with a left, level II neck mass, consistent with a branchial cleft cyst, per CT imaging. Patient opted for surgical removal (CPT 42815) vs. FNA.
Surgical specifics:
A #15 blade was used to incise in the planned incision line. The incision was carried down to the subplatysmal layer. The subplatysmal flap was then elevated with a #15 blade superiorly approx. 1.5 inches. Subplatysmal flap was then elevated inferiorly with Bovie cautery. Stay hooks were placed to the open wound. The mass was identified anterior to the sternocleidomastoid muscle. Dissection anteriorly across the mass was accomplished. Hemostat dissection to free the capsule from surrounding tissue was accomplished. Bovie cautery and subsequent bipolar cautery were used to provide hemostasis and to transect tissue. Dissection was carried out anteriorly down to the internal jugular vein. The internal jugular vein was identified. Dissection inferiorly and laterally were then accomplished. The sternocleidomastoid muscle was freed from the mass itself. The mass was fully mobilized and then dissection was carried out superiorly. Dissection on the the capsule superiorly with hemostat and bipolar cautery was accomplished. Dissection up to the digastric muscle was then performed. Digastric was freed from the mass itself. Mass was fully mobilized inferiorly and retracted laterally. There did not appear to be a tract beyond the digastric muscle. The superior tissues were completely transected. Care was taken to protect the spinal accessory nerve deep to the mass. The mass was fully immobilized and then removed. There was a small lymph node inferiorly and this was removed with the mass. ...
Pathology came back indicating that the mass was Burkitt Lymphoma.
Needless to say CPT 42815 is not appropriate for this procedure after our surgical and pathology findings. We are leaning towards CPT 38510 but also wondering if 38724 could be appropriate.
Any help is appreciated!
Patient presented with a left, level II neck mass, consistent with a branchial cleft cyst, per CT imaging. Patient opted for surgical removal (CPT 42815) vs. FNA.
Surgical specifics:
A #15 blade was used to incise in the planned incision line. The incision was carried down to the subplatysmal layer. The subplatysmal flap was then elevated with a #15 blade superiorly approx. 1.5 inches. Subplatysmal flap was then elevated inferiorly with Bovie cautery. Stay hooks were placed to the open wound. The mass was identified anterior to the sternocleidomastoid muscle. Dissection anteriorly across the mass was accomplished. Hemostat dissection to free the capsule from surrounding tissue was accomplished. Bovie cautery and subsequent bipolar cautery were used to provide hemostasis and to transect tissue. Dissection was carried out anteriorly down to the internal jugular vein. The internal jugular vein was identified. Dissection inferiorly and laterally were then accomplished. The sternocleidomastoid muscle was freed from the mass itself. The mass was fully mobilized and then dissection was carried out superiorly. Dissection on the the capsule superiorly with hemostat and bipolar cautery was accomplished. Dissection up to the digastric muscle was then performed. Digastric was freed from the mass itself. Mass was fully mobilized inferiorly and retracted laterally. There did not appear to be a tract beyond the digastric muscle. The superior tissues were completely transected. Care was taken to protect the spinal accessory nerve deep to the mass. The mass was fully immobilized and then removed. There was a small lymph node inferiorly and this was removed with the mass. ...
Pathology came back indicating that the mass was Burkitt Lymphoma.
Needless to say CPT 42815 is not appropriate for this procedure after our surgical and pathology findings. We are leaning towards CPT 38510 but also wondering if 38724 could be appropriate.
Any help is appreciated!