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Postoperative Diagnosis: Right chest wall mass x2, status post reconstructive surgery following right masectomy for breast cancer, rule out local recurrences.
Procedure: Excisional biopsy x2, right chest wall.
Procedure in Detail:
The patient was taken to the operating room after obtaining informed consent and was placed on the operating table in a supine position. Following the achievement of adequate general endotracheal anesthesia, the patient's right breast and chest wall were prepped with Betadine gel and sterily draped. Attention was directed to the medical lesion first. A superficial lesion was present just beneath the skin with a reconstruction flap from a free flap chest wall reconstruction following breast cancer surgery. The lesion measured approximately 1.0 cm in diameter. An elliptical incision measuring 4.0 cm in legnth and 3.0 cm in width was used to widely locally excise this palpable abnormality. The specimen was forwarded to pathology and the wound was closed wityh interrupted 2-0 Vicryl suture of the deep dermal layer and 4-0 subcuticular Vicryl sutures with Steri-Strips for skin closure.
Attention was then directed to the lateral lesion, which was in the lateral aspect of the free flap just on the inside of the incision. The lesion was deep to the skin and an elliptical incision was not required. An incision was made over the mass and the mass was excised with electrocautery. The mass measured approximately 2.0 cm in diameter and had the appearance of the fat necrosis and scar tissue grossly. The hemostasis was obtained with the electrocautery. The wound was closed in layers with Vicryl sutures and Steri-Strips.
Would it be cpt code 19120 x2 or would it be cpt code 21555?
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