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Thread: Exploration and debridement of wound,breast

  1. #1

    Default Exploration and debridement of wound,breast

    Promo: Code Books
    Hi, can someone help me with the following surgery and DX? Thanks in advance

    The opened incision on the left breast was opened for
    a few millimeters medially, so the area could be probed. There was a
    tunnel that extended inferiorly for approximately 3 to 4 cm. The skin
    overlying this area was extremely thin and was preventing adequate
    drainage of this underlying tunneled cavity. The skin over the
    tunneled cavity was excised using a 15 blade. Blood supply was
    excellent. The wound was irrigated. There were actually signs of
    granulation tissue at the base of the wound. There was no significant
    tissue that was nonviable than the possibility of the skin that was
    excised. The wound was packed open using saline moistened Kerlix
    gauze. Sterile dressings and an ABD pad were applied. At the
    completion of the procedure, all sponge, needle and instrument counts
    were correct. Estimated blood loss was 20 mL. The patient tolerated
    the procedure well and was transported to the PACU in stable
    condition.

    The CPT I believe I should code 11042 and the DX I have is 879.0 OR 879.1 ( not sure if I should use the complicated one, does the doctor have to say complicated in order to use?) I was thinking complicated, based on the dx from the path. I also have 611.0 as well.
    Tha path report says:
    skin and underlying soft tisue showing acute and chronic inflammation with Foreign Body Giant Cell Reaction, No malignancy.

    I am not sure what to code for Foreign Body Giant cell reation. If I go under Reaction inflammatory, it brings me back to 611.0. Reaction FB brings me to 728.82. should I leave it as 611.0? I looked up the definition to this and found:Reaction in skin to the presence of foreign body includes granulomatous inflammation with giant cells.

    Thank you so much in advance!

  2. #2
    Join Date
    Apr 2007
    Location
    Johnson City
    Posts
    202

    Default

    I would consider using CPT code 19020. I've seen that same wording on path reports, it's usually when it's a cyst that has been previously drained, and is healing. Code 998.6 might be right, depending on if this wound is a non-healing post-surgical wound. If not would probably go with 879.0
    Melissa Jewett, CPC

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