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Help coding OP note

  1. #1
    Modesto, CA; Central Valley Chapter
    Default Help coding OP note
    Clearnace Sale
    Hi, can I get opinions on how this should be coded please?

    Her right breast was prepped in a normal surgical fashion. A
    small amount of methylene blue was placed into the sinus tract and then an
    elliptical incision was made around the sinus tract and the entire sinus
    tract was completely excised within the areolar nipple area. The portion of
    the nipple was tented down, and this was released. The incision had to be
    carried into the nipple complex to do this. Once this was all done,
    hemostasis was meticulously obtained and then the deep tissues were
    reapproximated using 3-0 Monocryl suture. Then 3-0 Monocryl suture was used
    to reapproximate the epidermis. A 4-0 chromic was used in a simple
    interrupted stitch fashion to reapproximate the epidermis. The nipple was
    left loosely put together and then a trans nipple stitch was placed at the
    base to help keep this projection.

    Tina Reich, CPC, CPC-I, CEMC

  2. Default
    I'm new to plastics (they just started doing the surgeries at my hospital) but I'd have to go with 19110 or 19112 depending on what caused sinus tract, along with 19350.
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

  3. #3
    Modesto, CA; Central Valley Chapter
    Tina Reich, CPC, CPC-I, CEMC

  4. Default duct exploration and intraoperative ultrasound breast lesion excisional biopsy
    Hi can I get opinions on how this should be coded please?

    The patient was brought to the operating room and placed supine on the table. We confirmed the procedure with the patient. She had consented. She was given a general anesthetic and prophylactic antibiotics. Prior to prepping and draping her left breast, I performed an ultrasound. I reviewed the ultrasound from Radiology done preoperatively and noted the lesion was at 3 o'clock position. I then performed an ultrasound and identified the ducts and I then clearly identified the intraductal mass at the 3 o'clock position. Its position on the patient was right under the areolar edge. I marked this for localization. We then prepped and draped in sterile fashion. I was able to express a discharge readily and I cannulated the discharging duct on the nipple with a lacrimal probe. I then made a curvilinear incision along the areolar border laterally and dissected down to identify the lacrimal probe within the duct that transversed toward 3:00 laterally. I dissected this duct using combination of sharp dissection and cautery until I went lateral to the region marked preoperatively. As I dissected, I feel that I did enter the duct and I could see a papillary growth, so I feel by gross examination, I confirmed that there was an intraductal papilloma. I suspected. I then removed about 3 cm of this duct and surrounding parenchyma and submitted this for pathology removing the lacrimal probe. I palpated the surrounding tissues. No other abnormalities were identified. No abnormal masses. I irrigated and then closed the subcutaneous Vicryl and I injected Marcaine for postop analgesia. I closed the subcutaneous Vicryl, parenchymal Vicryl and Monocryl in the dermis and Dermabond. She tolerated this well and was then taken to the recovery in stable condition. Our final counts were correct.

    My opinion is 19125 and 76942. Please verify and suggest whether is this correct coding or suggest the right codes... Thanks in advance

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