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Just 19380? Fat grafting is throwing me off?

  1. #1
    Default Just 19380? Fat grafting is throwing me off?
    Medical Coding Books
    Post Operative Note
    Department of Plastic Surgery
    Procedure Date:
    Surgeon(s): Assistant(s): None
    Preoperative Diagnosis: deformity of bilateral reconstructed breasts
    Postoperative Diagnosis: same
    Procedure Performed: Revision of bilateral reconstructed breasts
    Right superior breast fat grafting - 30.5cc
    Left superior breast fat grafting - 18cc
    Left lateral breast fat grafting - 42cc
    Anesthesia:Anesthesia of Choice
    Anesthesiologist:Anesthesiologist:
    Anesthesiologist Assistant:
    Antibiotics: ancef 2 gm IV
    Complications: none
    IV Fluids: 900ml
    Estimated Blood Loss: Minimal
    Specimens: None
    Condition of Patient:
    The patient was transferred in stable condition.


    Summary:
    The patient was transferred to the OR and placed into a supine position. General LMA anesthesia was induced. The patient was prepped and draped. A formal timeout procedure was then performed. Once all members of the operative team were in agreement the procedure commenced.
    A 1 cm incision was made in the abdominal midline at the suprapubic crease. 300cc of tumescent fluid was infiltrated into the soft tissues of the inferior abdomen. Suction lipectomy with hand suction removed a total of 180cc of fat from this area. The aspirated fat was the processed by centrifugation at 3000 rpm for 3 minutes. The upper lipid layer was removed with neuro pledgets and the lower blood level was poured off. The donor site was then equalized with a 5mm exploded basket cannula. The incision was then closed with interrupted 4-0 vicryl.


    The fat was then transferred to 3cc syringes. Stab incisions were made in the marked superior concavities of each breast at the 6 and 9 o'clock positions of the defects. A total of 30.5 cc of fat was transferred to the superior right breast, followed by 18 cc of fat to the superior left breast. Stab incisions were then made at the 3 and 6 o'clock positions of the left lateral defect. A total of 42cc of fat was then transferred to this area. Over correction was noted for each defect. The stab incisions were then closed with interrupted 4-0 polysorb. Foam tape was applied to the areas of fat grafting.
    Dressing sponges were applied to the region of liposuction followed by a compressive garment.
    Patient was allowed to awaken from anesthesia and the LMA device was removed. She was then transferred to the PACU in stable condition. The patient tolerated the procedure well, no complications. Count were correct x2.

  2. #2
    Default
    Correct

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