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Thread: Please help with correct codes!

  1. #1
    Join Date
    Apr 2007
    Daytona Beach, FL

    Default Please help with correct codes!

    AAPC: Back to School
    I have posted this on another forum with no response - probably should have posted it here. Please help - our surgeon performed two operations for what she called Revision of reconstructed breast - one looks like all she did was debride the tissue which I have as 11042-78 (can the closure be billed separately?), the other looks more like a revision, CPT code 19380-RT-78. Can someone review both of the OP notes below and advise me if these codes would be correct or if there is another code I should be using? I know this surgeon will insist that the they were both revisions and I need some assistance, as I am completely new at doing this type of coding.

    1. 11042-78

    PREOPERATIVE DIAGNOSIS: Left-sided breast cancer status post mastectomy and tissue expander reconstruction, with nonviable mastectomy skin.

    POSTOPERATIVE DIAGNOSIS: Left-sided breast cancer, status post mastectomy and tissue expander reconstruction with nonviable mastectomy skin.

    PROCEDURE PERFORMED: Revision of reconstructed left breast.

    SPECIMENS: One specimen to pathology (skin) and one specimen to microbiology, deep wound swabs.

    ANESTHESIA: MAC using an LMA.

    OPERATIVE FINDINGS: The nonviable skin was debrided. There was no purulence identified. There was no turbid fluid identified. The existing drain was left in place. The AlloDerm was intact at the base of the wound and was incorporating in some areas.

    DESCRIPTION OF PROCEDURE: After informed consent obtained, the patient was taken to the operating room. Patient has been on Keflex on an ongoing fashion and then Kefzol prior to surgery. The area was prepped and draped in the routine fashion and then the nonviable skin was debrided sharply. This was passed off as pathology specimen. The underlying subcutaneous tissue was evaluated and any fatty tissue that appeared dark yellow was debrided. This produced vigorous bright red bleeding. Then 3 liters of automated lavage was performed of normal saline. At the end of that, the culture swabs were taken from the deep portions along the wound and then 3 additional liters of normal saline with 50,000 units of bacitracin instilled into the 3 liter bag were then pulse lavaged. The wound was closed in layers with deep dermals 4-0 PDS figure-of-eight stitches followed by a running subcuticular closure. Dermabond was applied over top. The left drain dressing removed and replaced and then dry gauze was placed over top of the left breast. The patient had the LMA removed in the operating room and was taken to recovery room in stable condition. There were no intraoperative complications.

    2. 19380-RT-78

    PREOPERATIVE DIAGNOSIS: Breast cancer status post bilateral mastectomies with tissue expander reconstruction, currently with mastectomy skin loss along the right breast.

    POSTOPERATIVE DIAGNOSIS: Breast cancer status post bilateral mastectomies with tissue expander reconstruction, currently with mastectomy skin loss along the right breast.

    PROCEDURE: Revision of reconstructed right breast.

    ANESTHESIA: LMA with MAC and 10 cc of 1% lidocaine with epinephrine.

    DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room. A time-out was held in which the patient's name and procedure to be performed was verified. The nonviable full thickness skin loss was marked out and then superficial subdermal field block was performed with 1% lidocaine with epinephrine. The incision was then made full thickness down through skin into the subcutaneous tissue. This resulted in a skin deficit that was elliptical shaped in the transverse dimension and inverted V-shape in a vertical dimension along the mid portion of the wound. The inverted V was advanced along the wound and closed in a linear fashion with a T-junction with the transverse incision. Once the excision of nonviable skin was performed, this was passed off as a pathology specimen. The resultant wound was carefully evaluated. Any questionable appearing subcutaneous tissue was debrided and then 3 liters of automated pulse lavage was performed. Deep swabs were taken of the exposed tissue and then another 3 liters with gentamicin of automated pulse lavage was performed. The mastectomy skin flaps were milked in order to remove any of the remaining irrigation fluid. Two-layered closure was performed with 4-0 PDS and then deep dermal interrupted and then 4-0 Monocryl running closure. Along the T-junction, the superior vertical incision was closed with 5-0 fast absorbing plain. Dermabond was applied over the wound and then dry gauze and a Tegaderm was applied as a final dressing. Patient was awoken. The LMA was removed in the operating room. There were no complications. She was taken to the recovery room in stable condition.

    Thank you for all the help I can get!
    Jodi Dibble, CPC

  2. #2
    Join Date
    Apr 2007
    Charleston, WV


    I agree on the first procedure. I'm not sure the second procedure constitutes a reconstruction, though. I think I would code it as a debridement as well. 19380 generally reports some change to the breast material, not just the skin (ie: a change in shape or size). Closure is included in the debridement.

  3. #3
    Join Date
    Apr 2007
    Daytona Beach, FL


    Thank you very much for your response! This was very helpful.
    Jodi Dibble, CPC

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