Please help! - Breast--IRRIGATION & DEBRIDEMENT BREAST WOUND / ABSCESS

KBean2018

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Hello, which debridement code should I use along with implant removal code?

Operative Procedure: A 3.5 cm diameter circle at her mastectomy scar, and a 2.5 cm diameter circle superiorly where her tissue expander port site was previously located. Her implant is grossly visible at both of these locations. There is a thin intervening skin bridge connecting these 2 locations. With her consent a photo was taken in preoperative holding area and scanned into media prior to surgery. The skin bridge is clearly not viable and it is incised. The implant is removed and sent to pathology for gross examination. The implant pocket is then copiously irrigated with 3 L of pulse lavage saline. There is an inflammatory rind evident in the pocket. However there is no gross purulence. At the level of the prepectoral plane under direct visualization using cautery the skin flaps are elevated circumferentially. Using a 15 blade the skin edges were then debrided to remove the circular skin defects which leads to a vertical defect measuring 11 cm her left chest wall. The skin edges do bleed with this tissue removed. The mastectomy skin is sent to pathology for examination. 30 cc of quarter percent Marcaine with 1:100,000 epinephrine is injected for local anesthetic and hemostasis. With the wide undermining I am able to close the skin flaps with only minimal tension. Hemostasis is achieved using cautery. Saline was used for additional irrigation. A 10 French round JP drain is placed within the pocket. 3-0 Vicryl sutures were used to reapproximate the dermis. 4-0 Monocryl horizontal mattress sutures were used to loosely reapproximate the skin edges. A 13 cm Prevena incisional wound VAC is placed over the incision. A drain sponges placed around the drain site. The patient was awoken from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire case.
*

thank you :)
 
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Hello KBean2018,

Without reviewing the path report, I am thinking either CPT 13101-51 & 13102-51 (since the size of the defect is 11 cm) or since the documentation mentions "the skin edges do bleed with this tissue removed. The mastectomy skin is sent to pathology" maybe CPT 19304 :confused:? Here is the definition of both codes:

CPT 13101: The physician repairs complex wounds of the trunk. The physician debrides the wound by removing foreign material or damaged tissue. Irrigation of the wound is performed and antimicrobial solutions are used to decontaminate and cleanse the wound. The physician may trim skin margins with a scalpel or scissors to allow for proper closure. The wound is closed in layers. The physician may perform scar revision, which creates a complex defect requiring repair. Stents or retention sutures may also be used in complex repair of a wound. Reconstructive procedures, such as utilization of local flaps, may be required and are reported separately. Complex wounds require additional special treatment, such as the use of stents, dressings, retention sutures, or extensive revision, which may involve removing sizable portions of skin or extensive undermining the skin to loosen the tissues to close a defect.

CPT 19304:The physician performs a subcutaneous mastectomy. The physician makes an incision in the inframammary crease. The breast is dissected from the pectoral fascia and from the skin. The breast tissue is removed, but the skin and pectoral fascia remain. The physician may ligate any bleeding vessels. The nipple and areola may be examined by a pathologist and retained if free of disease. If no prosthesis is to be inserted, a closed wound suction catheter may be inserted. The wound is closed and a light pressure dressing is applied.

Hope this somewhat helps :)

M.Hannus, CPC, CPMA, CRC
 

KBean2018

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So grateful for your feedback!

Thank you so much meghanhannus. I was going to use 19328 for the removal of the implant. I notice with the 13101 & 13102 they bundle and require modifier 59. Do you think it would be appropriate to add modifier 59?

path report states: FINAL PATHOLOGIC DIAGNOSIS
A. FOREIGN BODY LABELED "LEFT BREAST IMPLANT", REMOVAL:
*****FOREIGN BODY CONSISTENT WITH BREAST IMPLANT (GROSS DIAGNOSIS
ONLY).

B. TISSUE LABELED "LEFT BREAST MASTECTOMY SCAR":
*****SKIN SHOWING FOCAL DERMAL AND SUBCUTANEOUS ACUTE AND CHRONIC
INFLAMMATION WITH FOCAL HEMORRHAGE COMPATIBLE WITH CHANGES
RELATED TO PREVIOUS PROCEDURE.
 
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Thank you so much meghanhannus. I was going to use 19328 for the removal of the implant. I notice with the 13101 & 13102 they bundle and require modifier 59. Do you think it would be appropriate to add modifier 59?

path report states: FINAL PATHOLOGIC DIAGNOSIS
A. FOREIGN BODY LABELED "LEFT BREAST IMPLANT", REMOVAL:
*****FOREIGN BODY CONSISTENT WITH BREAST IMPLANT (GROSS DIAGNOSIS
ONLY).

B. TISSUE LABELED "LEFT BREAST MASTECTOMY SCAR":
*****SKIN SHOWING FOCAL DERMAL AND SUBCUTANEOUS ACUTE AND CHRONIC
INFLAMMATION WITH FOCAL HEMORRHAGE COMPATIBLE WITH CHANGES
RELATED TO PREVIOUS PROCEDURE.
You're welcome :)

Yes, I think modifier 59 would be appropriate since CPT 13101/13102 are to address the scar excision/debridement/closure.
 
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