I need recommendations on how to code a procedure. The Dr. performed a right nipple delay procedure for nipple preservation. DESCRIPTION OF PROCEDURE: General anesthesia was induced. An inframammary
fold incision was created as centrally. Using electrocautery and sharp
dissection, the anterior skin flaps were created across the chest wall. The
breast tissue was extremely soft and fatty and easily dissected away from the
skin. The flaps were thinner essentially than ultimately desired and the
flaps were taken towards the level of the clavicle as well as the sternum
given the thinness of the central portions of the flap periareolarly. I
opted to discontinue our further dissection at this point saving this for
lateral date. The nipple was able to be nicely elevated off of the breast
fat with the retroareolar portions being sent for permanent sectioning.
Satisfactory hemostasis was assured. The created skin flaps appeared pink
and viable, hemostatic upon completion.
I billed 19301,22,58 then two weeks later, there was a Bilateral simple Mastectomy with Left sentinel node biopsy 19303,58 RT,LT 38525,LT
Is this correctly Billed?
fold incision was created as centrally. Using electrocautery and sharp
dissection, the anterior skin flaps were created across the chest wall. The
breast tissue was extremely soft and fatty and easily dissected away from the
skin. The flaps were thinner essentially than ultimately desired and the
flaps were taken towards the level of the clavicle as well as the sternum
given the thinness of the central portions of the flap periareolarly. I
opted to discontinue our further dissection at this point saving this for
lateral date. The nipple was able to be nicely elevated off of the breast
fat with the retroareolar portions being sent for permanent sectioning.
Satisfactory hemostasis was assured. The created skin flaps appeared pink
and viable, hemostatic upon completion.
I billed 19301,22,58 then two weeks later, there was a Bilateral simple Mastectomy with Left sentinel node biopsy 19303,58 RT,LT 38525,LT
Is this correctly Billed?