JoannaWelch
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I would appreciate any assistance in CPT coding of the following procedure note: This is on a MALE patient.
Wide Excision of Malignant Neoplasm of skin, soft tissue, and muscle on chest wall 10cm
Patient has been noncompliant with plan of treatment for right breast cancer. A 1.5 cm margins were marked around it based on palpation to remove lesion and any grossly involved tissue. The tumor measured 10 cm. It appeared to be still mobile. There was no palpable masses axilla. The tumor was sharply excised with the adjacent skin and soft tissue by developing a superior, inferior and medial lateral flaps and down to the pectoralis major. Vessels were ligated with 3-0 Vicryl or cauterized. Once the fascia was reached, the fascia was removed with the tumor until the underside of the lesion was reached. In effect, it was a simple mastectomy that was performed. Irrigation performed, hemostasis was obtained. Vessels were tied with 3-0 Vicryl and tissue was reapproximated with O Vicryl, 2-0 Vicryl and 2-0 nylon.
Any suggestions? I may be overthinking this.........
Wide Excision of Malignant Neoplasm of skin, soft tissue, and muscle on chest wall 10cm
Patient has been noncompliant with plan of treatment for right breast cancer. A 1.5 cm margins were marked around it based on palpation to remove lesion and any grossly involved tissue. The tumor measured 10 cm. It appeared to be still mobile. There was no palpable masses axilla. The tumor was sharply excised with the adjacent skin and soft tissue by developing a superior, inferior and medial lateral flaps and down to the pectoralis major. Vessels were ligated with 3-0 Vicryl or cauterized. Once the fascia was reached, the fascia was removed with the tumor until the underside of the lesion was reached. In effect, it was a simple mastectomy that was performed. Irrigation performed, hemostasis was obtained. Vessels were tied with 3-0 Vicryl and tissue was reapproximated with O Vicryl, 2-0 Vicryl and 2-0 nylon.
Any suggestions? I may be overthinking this.........