Bwray
Contributor
If the patient had a simple mastectomy with TRAM flap reconstruction and returns to the OR for recurrent breast cancer involving the TRAM flap how would you code this?
OP Report reads: Flaps were raised at the clavicle, parasternum and latissimus dorsi. In order to get the breast off I had to get in the subpectoral plane, raise the breast off the muscle with Bovie cautery. Once the breast was lateralized a complete three-level axillary lymphadenetomy was carrid out skeletonizing the axillary vein, thoracodorsal neurovascular bundle and the long thoracic nerve. The nerves were proserved, I also used a Harmonic scalpel to track up along the axillary vien inferiorly up to where it penetrated the thoracic fascia. Those nodes were submitted as the highest level III nodes. The wound was closed in a T-fashion in order to get it closed. Patient taken to recovery room in excellent condition having tolerated the procedure well.
CPT 21558 and CPT 38745 is what I found.
Any suggestions would be helpful.
OP Report reads: Flaps were raised at the clavicle, parasternum and latissimus dorsi. In order to get the breast off I had to get in the subpectoral plane, raise the breast off the muscle with Bovie cautery. Once the breast was lateralized a complete three-level axillary lymphadenetomy was carrid out skeletonizing the axillary vein, thoracodorsal neurovascular bundle and the long thoracic nerve. The nerves were proserved, I also used a Harmonic scalpel to track up along the axillary vien inferiorly up to where it penetrated the thoracic fascia. Those nodes were submitted as the highest level III nodes. The wound was closed in a T-fashion in order to get it closed. Patient taken to recovery room in excellent condition having tolerated the procedure well.
CPT 21558 and CPT 38745 is what I found.
Any suggestions would be helpful.