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Thread: Help with surgery code for this operative report

  1. #1

    Default Help with surgery code for this operative report

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    PREOPERATIVE DIAGNOSIS: Hematoma mastectomy wound. Need for IV antibioitics


    OPERATION: Exploration of mastectomy wound with evacuation of hematoma, placement new drains, and application of thrombin

    PROCEDURE AND FINDINGS: Patient was brought to thie operating room, properly identified, placed on the table in supine position. Preop diagnosis, procedure and site were confirmed. General anesthesia was induced via IV and LMA. She received a gram of IV Ancef immediately preop. She also had sequential TEDS placed. All of the clips, sutures, and drains were pulled from the mastectomy site, and then the site, chest wall and arm was prepped twice with Betadine and drapes applied. The previous incision was opened, it was showing signs of poor healing as it opened with just blunt finger dissection. There was not a large amount of hematoma present, but there was someoverlying the upper lateral aspect of the pectoralis, and also in the trough in the lateral inferior wound. After evacuation of hematoma, the wound was irrigated with saline and water, and small oozing areas were controlled with electrocautery. Additional muscle and pectoralis fascia was excised in the area where the medial tumor was present, as there was a question of posterior margins in this region. The wound was again inspected and there was no bleeding. Next, several mm of skin edge was sharply excised with scalpel, back to viable bleeding skin edges. Hemostasis was again accomplished with electrocautery. Finally, thrombin topical was sprayed over the entire surface of the pectoralis and subcutaneous tissue to enhance hemostasis and two round J-Vac drains were placed and brought out through separate stab incisions, and the drains were sutured to the skin with 3-0 nylon. The wound was then closed by dividing it into equal parts with 3-0nylon puley sutures. In between this, horizontal mattress sutures of 3-0 nylon were used for better hemostasis, and finally, in between these areas, Proximate clips were used to close to the skin. There were no undue tension on the skin edges, and there was absolutely no sign of bleeding at the end when the Hemovacs were attached to the reservoirs. Xeroform dressing was applied, then dressings and fluff dressings, then finally 6 inch Ace X @ was used to wrap the chest wall for compression dressing.

    FYI..This patient had the modified radical mastectomy, CPT 19307, 7 days prior to the procedure described above.

    The surgeon gave us an unlisted procedure code 19499.

    Does anyone have a suggestion as to how to code this?

  2. #2


    Look at 10140 with 78 modifier.

    V. Kratzer

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