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Exploration of right chest wall, right cervical lymph node biopsy with frozen section

  1. Default Exploration of right chest wall, right cervical lymph node biopsy with frozen section
    Medical Coding Books
    Hi, all. Thanks for checking this out. Any input would be greatly appreciated. I'm fairly sure that I can bill SOMETHING for the exploration, seeing as it was a different incision. I'm just at a loss as to what....

    The patient was taken to the operating room after induction of adequate anesthesia, the patient was prepped with DuraPrep and draped sterilely. Perioperative antibiotics have been administered. The skin was infiltrated over the palpable mass in the right chest. The possibility that this was a breast lesion was entertained. The incision was carried down through subcutaneous tissues. Ultimately it was apparent that it was deep to the musculature. The pectoralis musculature was divided and it actually was still deep and was not well defined. Ultimately, the decision was to abandon this biopsy as the cervical lymph node was more clearly a metastatic focus. The wound was inspected for hemostasis, it was closed with 3-0 Vicryl deep tissue and 4-0 Vicryl subcuticular stitch. Steri-Strips and Tegaderm applied. The patient tolerated the procedure.

    With this completed, the right neck was addressed in the supraclavicular area just lateral to the clavicular head of the sternocleidomastoid. The skin was infiltrated with Marcaine and incision was made with a #15 blade. Musculature was retracted. Ultimately, the mass was visualized. The area was carefully retracted and the lesion was biopsied. The tissue was extremely friable. Frozen section report suggests that it is probably of small cell carcinoma. Additional tissue was provided for permanent section. Final pathology is pending. The wound was inspected for hemostasis. It was then closed in layers utilizing 3-0 Vicryl to the deep tissue and a 4-0 Vicryl subcuticular stitch. Steri-Strips and Tegaderm applied. The patient tolerated the procedure. The estimated blood loss was perhaps 15 mL.

  2. #2
    Milwaukee WI
    Default 19101
    Since it seems that the intention was for a biopsy of a breast mass, I would use 19101 with -53 modifier (showing that the procedure was discontinued).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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