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19101 vs 19125

  1. #1
    Default 19101 vs 19125
    Medical Coding Books
    doc did a needle localization but also excsion of some nipple, would this qualify for a partial mastectomy -19301?. I dont see any margins invoved ?So I am leaning towards 19125 , but his office says leave it as the booking which was 19301?, not sure if this is right
    anyone agree ? op note

    POSTOPERATIVE DIAGNOSIS: Right breast mass via mammography and inverted nipple.
    OPERATION: Right needle localization breast biopsy with excision of some nipple.
    After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, underwent general anesthesia with laryngeal mask anesthesia and was prepped and draped in a normal fashion. The patient had been examined by me in the preoperative holding area. A time-out had been performed to correct the patient and correct procedure and the right breast was prepped and draped with DuraPrep solution. Five minutes were waited prior to using Bovie cauterization after the DuraPrep was placed. Parenteral antibiotics had been given prior to skin incision. The wire had been located and an incision that included a mastectomy, the skin around the wire was incised and the wire was in the middle of it and then around the nipple areola on the right. This was very close to her skin. She had a previous core biopsy. There was a hematoma associated with this. The entire wire with surrounding area was removed. Again, this is very close to the nipple areolar area. The entire specimen was removed. It was around 4 to 5 cm and sent to Radiology to confirm that we had a lesion. After doing this, I flipped the nipple up with my finger and noticed some ulceration in the middle of the nipple. Because of this, the nipple was then excised with a pie-shaped fascia for 2 cm. Excellent hemostasis noted to be obtained. The nipple area was closed with 3-0 nylon in interrupted fashion. Radiology called back that we indeed have the lesion; there was no longer in the patient. It was out of the patient. It was in the specimen that was removed. Excellent hemostasis was noted to be obtained. The skin was closed with 3-0 nylon in horizontal mattress fashion.

    thanks any suggestions ?

    Sterile dressing was placed. The patient tolerated the procedure well, was transferred to the recovery room in stable condition.

  2. #2
    More I read it know want to go towards 19101

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