I am needing someone's opinion in regards to the correct codes for this procedure. I work at an ASC & it's for a commercial payer. I am thinking I have too many codes but maybe not. I believe all of the CCI edits were ok.
Here is the op report:
1. Bilateral breast grade IV capsules.
2. Implant malposition bilaterally.
3. Status post subcutaneous mastectomies for severe fibrocystic disease.
POSTOPERATIVE DIAGNOSES: Bilateral ruptured silicone implants.
1. Bilateral implant removal and exchange (Mentor 575 cc saline implants, right side filled to 625 cc, left side filled to 575 cc).
2. Bilateral breast reconstruction pocket revision.
3. Bilateral complete capsulectomies, severe.
INDICATION: female who many years ago had bilateral mastectomies for severe fibrocystic disease. She had bilateral silicone implants placed. Over the years she has developed significant capsular contracture, pain in both breasts and breast asymmetry secondary to the capsular contracture. The patient was unaware that she had ruptured silicone implants on both sides. This was identified intraoperatively.
FINDINGS: Bilateral silicone implant rupture. Implants were 230 cc bilaterally.
DESCRIPTION OF PROCEDURE: The patient was preoperatively marked in the holding room in the standing position. She was taken to the operating theater where general anesthesia was induced. One gram of Ancef was given prior to starting the procedure. Starting on the left side we infiltrated 5 cc into the superior aspect of the pectoralis major muscle and some in the subcutaneous portion of the incisions. This was done on both breasts. At this point in time we started on the left side, making an inframammary incision. The patient had some unusual incisions for her mastectomies. We did not follow those lines. We made an incision in the lower portion of the breast just above the presumed inframammary fold, dissected down until we identified pericapsular tissue. Dissection around the pericapsular tissue was done as far as we could and then we had to open up the implant pocket, which as soon as we did we immediately identified that the patient had a ruptured silicone implant on the left side. This was removed and placed in a sterile towel. The breast was irrigated with copious amounts of normal saline solution and also Betadine solution to try to break up the silicone that was ruptured within the breast cavity. Once that was completed attention was turned to the right breast. Similar dissection on the inframammary area was carried down until we found the pericapsular tissue, opened it, and removed the ruptured implant on the right side also. Again this pocket was irrigated with copious amounts of normal saline solution and also Betadine solution. Once we had both pockets irrigated the pectoralis major muscle was infiltrated with 20 cc of 0.25% Marcaine with epinephrine. We did a complete capsulectomy on both sides, removing 90% of the capsule. The areas where it was significantly adhered to the overlying rib cage we left. Once that was completed we chose the Mentor 575 cc saline implants. They were placed in the submuscular position. The pockets were irrigated once again. A #19 Blake was placed in the pocket also and the inframammary incision was closed with 3-0 Vicryl sutures and 3-0 Prolene subcuticular stitch. Two-inch foam was place around the breasts. She was returned to the PACU in stable condition and extubated. Both pockets were revised by opening up the tissues both superiorly and medially. This was done on both the right and left sides. We gained more room for the larger implants. Laterally when we removed the capsule it did make more room for the implants. We left a small strip of capsular tissue at the inframammary fold so that the implants would not fall or bottom out. Once the implants were in position we also did pocket revision to try to smooth out the irregularities caused by the old scars. Again, once we were done with that the wounds were irrigated and closed with 3-0 Vicryl, 3-0 Prolene subcuticular stitch, and Steri-strips.
I would appreciate anyone's input in regards to these!
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