I wanted to get some opinions regarding these CPT codes, also the doctor states in the operation portion of the report that he did a left breast bx times two and a right breast bx (I do have a path report) but I don't clearly read it in the report, am I not seeing something or should he add an addendum to this report discussing the biopsies? I work at an ASC and it's for a commercial payer. I come up with these codes so far:

11970-LT
19342-LT
19371-LT
19318-RT


PREOPERATIVE DIAGNOSES:
1. Left breast cancer.
2. Status post left modified radical mastectomy.
3. Status post left breast tissue expander placement.
4. Breast asymmetry.

POSTOPERATIVE DIAGNOSES:
1. Left breast cancer.
2. Status post left modified radical mastectomy.
3. Status post left breast tissue expander placement.
4. Breast asymmetry.

OPERATION:
1. Left breast tissue expander removal and permanent implant placement (Mentor 800 cc implant filled to 1000 cc).
2. Left breast pocket revision with lowering of the inframammary fold and the lateral recess, also removing significant scar tissue bands.
3. Left breast biopsy times two; tissue submitted for pathology.
4. Right breast reduction, removal of 780 grams.
5. Right breast biopsy; tissue submitted for pathology.


INDICATION: The patient is a 60-year-old female who was diagnosed with left breast cancer. She has already undergone a left modified radical mastectomy and has undergone tissue expansion. She is now here for removal of tissue expander and placement of permanent implant. She does have grade IV capsular contracture that will require capsulectomy and capsulotomy, which both were performed today. She also has severe breast asymmetry with the right breast being significantly larger and more ptotic, so we plan on doing a right breast reduction.

FINDINGS: As above.

PROCEDURE: The patient was preoperatively marked in the holding room in the standing position and then taken to the operating room theater where general anesthesia was induced. One gram of Ancef was given prior to starting the procedure. Instead of going through the old scar, due to the fact that the patient has had radiation therapy and that tissue is very thin, we used an inframammary incision. We placed this lower than the breast implant itself because we knew we were planning on lowering the inframammary fold. Tissues were entered with a 15-blade dissection with electrocautery to identify the pericapsular tissue, identify the left breast tissue expander, opened it, and then popped the tissue expander for removal. Once it was removed we removed the lower pole of scar tissue, lowering the inframammary fold and gaining more access for the larger implant. We also removed capsular tissue in the medial aspect and lateral aspect. There were several significant bands that required release so that we could fit the new implant in there and also take out some of the puckering that was forming on the breast itself. The patient had a significant bulge in the left axillary area secondary to redundant tissue that we liposuctioned. We removed approximately 100-150 cc of subcutaneous tissue from that area. The implant that was chosen was the 800 cc Mentor moderate profile plus implant. We placed this in the submuscular position and inflated it to the maximum of 1000 cc. Once we had closed the incision on the left side with 3-0 Vicryl sutures and a 3-0 Prolene running suture, we turned our attention to the right breast which required reduction. Using a standard keyhole incision we de-epithelialized an inferior pedicle, removed the medial, superior and lateral breast tissue from the flaps, removing 780 grams of tissue from that right side. The inferior pedicle was elevated. The tissues were closed with 3-0 Vicryl and 4-0 Vicryl sutures, 3-0 Prolene and 5-0 Prolene sutures. A #19 Bard drain was placed in the breast pocket and also in the reconstructed side for postoperative drainage. Steri-strips were applied. The patient tolerated the procedure well.

Any suggestions/comments are appreciated!

Susan