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Mastectomy with repair

  1. #1
    Sioux Falls, SD
    Default Mastectomy with repair
    Medical Coding Books
    How would you code this OP note? This particular doctor codes her own surgeries and has selected a 19301, 38525 and 14001. It seems to me that the 14001 is not an appropriate code based on the dictation. I am debating if 19318 is appropriate, or if the repair would be included in the 19301. Also, does stating that she went through the subcutaneous tissues qualify for a deep biopsy, or would you use 38500? Thank you for any input!

    The left axilla was initially addressed. A curvilinear incision was
    made, and this was taken down through subcutaneous tissues. Dissection
    was carried out into the axilla. A gamma probe was inserted. Increased
    uptake was identified in several lymph nodes. These were dissected
    free of their attachments, completely removed, and sent to pathology
    for further evaluation. The axilla was then palpated. No discrete
    masses were identified. The incision was then closed using 3-0 Vicryl
    in interrupted fashion, 4-0 Monocryl in running subcuticular fashion.

    The left breast was addressed. Through a donut mastopexy incision
    nipple areolar incision was made circumferentially, and the tissue was
    de-epithelialized. Incision was then extended down towards the
    guidewire. The guidewire was identified, dissected free of its
    attachments, completely removed, and sent to pathology for further
    evaluation. Flaps were then raised superiorly and inferiorly, and the
    tissue edges were brought together. Hemoclips were placed within the
    wound to identify for future mammograms. The wound was then irrigated.
    The incision was then closed using a 5-0 Gore-Tex in a pursestring
    fashion followed by 3-0 Vicryl in interrupted fashion and 4-0 V-Loc in
    a running subcuticular fashion.

  2. #2
    Fayetteville, NC
    I believe the closure is included in the procedure. I would not code 14001.
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

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