Okay, I bill for a surgeon who states that he performs a oncoplastic reconstruction procedure with every mastectomy. For this note he coded the reconstruction using 19318 because he used a keyhole approach. To me it seems that this should not be billed separately, since the closure is part of the mastectomy. Also, I think a more appropriate code would be 19366. Please give help.

PREOPERATIVE DIAGNOSIS: Invasive ductal carcinoma, left breast.

1. Invasive ductal carcinoma, left breast.
2. Metastatic carcinoma at left axillary sentinel lymph node.

1. Left axillary sentinel lymph node biopsy.
2. Left axillary lymph node dissection.
3. Segmental mastectomy left breast lesion.
4. Oncoplastic reconstruction left breast (breast reduction type; keyhole).

INDICATIONS FOR PROCEDURE: Patient is an 84-year-old white female recently found to have invasive ductal carcinoma of the left breast at 6:00 radian. The patient has no known metastatic disease in the ipselateral axilla.

FINDINGS and PROCEDURE: One sentinel lymph node was located and separately evaluated. The SLN contained tumor. The left axillary dissection was successfully accomplished. The segmental mastectomy and oncoplastic reconstruction of the left breast were also satisfactorily completed.

The patient was brought to the Operating Room and placed on the operating table in the supine position. A Time Out procedure was accomplished. The patient was correctly identified as to identity, proposed procedures, and correct operative sites. The patient had already undergone radioisotope injection.

After satisfactory general anesthesia had been accomplished, the left breast and axilla were prepped and draped in the usual sterile fashion. A Neoprobe gamma probe was then advanced over the axilla and the site of maximal activity was identified in the mid axilla.

At this point, a left axillary incision was made and carried down to subcutaneous fat. The axillary fascia was then incised and the axilla entered. Utilizing the Neoprobe for guidance, the axilla was searched for nodes that were radioactively hot. One sentinel lymph node was discovered and removed. (See radioactivity count sheet, which is part of the operative record.) At this point, markedly diminished radioactivity was noted within the axilla (total counts were < 10%). The frozen section results revealed tumor in the sentinel node. Therefore, the sentinel lymph node biopsy was terminated and converted to a full axillary lymph node dissection.

The left transverse axillary incision was enlarged and carried down through subcutaneous fat. At this point, flaps were elevated superiorly and inferiorly at the left axilla. The claviculopectoral fascia was incised and the axilla was entered. The axillary vein was identified and preserved. The axillary contents were then excised from the axilla, beginning approximately 1 cm inferior to the axillary vein. Level I and Level II nodes were removed. The Long Thoracic, Thoracodorsal, and Intercostal-Brachial nerves were identified and preserved. Hemostasis was achieved using electrocautery where appropriate, and Harmonic scalpel and hemoclips where appropriate. The axillary contents were then removed. The wound was inspected for bleeding and there was none. The wound was irrigated with sterile water. At this point, a flat 17 Fr. fluted Jackson-Pratt drain was inserted without difficulty and anchored to the skin with #3-0 nylon suture. Subcutaneous fat in the axilla was then closed using a running #3-0 Vicryl suture. Skin was closed using a running subcuticular #4-0 V-Loc suture and Steri Strips. The drain was activated.

Gowns and gloves were changed. The left breast was prepped again and additional drapes were placed. The left breast was prepped and draped in the usual sterile fashion. After evaluating the wire localization mammograms, the proposed incision (left breast reduction type; keyhole) was then marked on the patient's breast. The incision was made and carried down through subcutaneous fat. An inferior trapezoidal button of skin and a circumareolar circle of skin were incised, allowing for superior-medial of the nipple. The inferior aspect of the skin was removed with the specimen. The superior aspect of the periareolar skin was defatted. The inframammary crease incision was made and carried down to chest wall muscle. Hemostasis was achieved with electrocautery. Utilizing electrocautery, the targeted breast parenchyma was excised with approximately a 1 cm margin of fatty fibrous tissue. The incision was carried down to the pectoralis muscle fascia and a trapezoidal button of fascia was removed en bloc with the specimen. Bleeding was controlled with electrocautery and #4-0 Vicryl sutures. The specimen was removed and the specimen was marked with multiple markers for pathological orientation. A specimen radiograph was not requested. A frozen section was not requested. The breast parenchyma and pectoralis fascia were then elevated peripherally in all directions from the chest wall for approximately 5 cm, especially medially and laterally. The wound was inspected for bleeding and several small bleeding sites were cauterized. Several mini-hemoclips were then used to mark the region of the primary carcinoma. There being no further bleeding, the breast parenchyma was reapproximated using multiple interrupted sutures of #2-0 Vicryl. Prior to closure of the parenchyma, a 17 Fr. fluted flat drain was placed against the chest wall (beneath the pectoralis fascia closure) and brought out through a separate stab wound. Interrupted #2-0 Vicryl and #4-0 Vicryl sutures were used to approximate the breast parenchyma at multiple levels. The nipple-areolar complex was then reapproximated to the subcutaneous tissues. The subcutaneous fat was closed using interrupted #4-0 Vicryl sutures around the nipple-areolar comlex. Skin was closed at the vertical incision and the transverse incisions with #4-0 V-Loc sutures. The skin around the nipple-areolar comlex was closed using two running subcuticular #4-0 Monocryl sutures and Steri-Strips. Dry sterile dressing was applied, and the patient having tolerated the procedures well, was awakened and taken to the PACU in good condition. Sponge, needle counts correct x3, instrument count correct x2. Estimated blood loss was minimal.