THE CODING EDGE® ARCHIVES

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Coding Recommendations - Feature Article 11/15/99
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" patient report.

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Read Discharge Summary


  

Preoperative Diagnosis: Status post right mastectomy and chemotherapy for stage I adenocarcinoma in 1997; for breast reconstruction. Small left breast.

Postoperative Diagnosis: Same

Procedure Performed: Delayed right breast reconstruction and left breast augmentation for symmetry-patient desires to be a B cup on both sides.

Operative Procedure: The patient was taken to the Operating Room and placed in a supine position on the OR table. After adequate general endotracheal anesthesia, the chest was prepped and draped in standard sterile fashion. Both breasts were marked with the pen and inframammary lines were drawn.

Attention was paid to the left breast. A 3 cm incision was made along the inframammary line to the level of the areola. The incision was carried out over the pectoralis fascia and dissected up toward the clavicle. Following the premarked guidelines, a pocket was then fashioned using blunt and sharp dissection. The wound was thoroughly irrigated. Bleeding was controlled with electrocautery. A 220 cc textured round implant was then placed into the pocket and filled to a total of 220 cc.

Attention was now turned to the right side. Using sharp dissection, an incision was made along the site of the previous mastectomy scar and carried down to the pectoralis fascia. Small flaps were raised both superiorly and inferiorly over the pectoralis. The pectoralis was then divided along the length of its fibers for approximately 3-4 cm. A pocket was fashioned beneath the pectoralis and the medial and inferior attachments of the pectoralis were released. After the pocket was created the wound was thoroughly irrigated and all bleeders controlled with electrocautery. A 500 cc tissue expander was then evacuated of all air, tested for leaks, positioned in the pocket and filled to a total of 100 cc saline.

The patient was now repositioned in the sitting position. The expander and implant appeared to be at good levels and the left breast appeared to be in satisfactory position.

The fascial layer of the left breast incision was then closed with interrupted sutures of 4-0 Vicryl and the skin closed with interrupted subcuticular sutures of 4-0 Vicryl. The right breast was closed with interrupted 4-0 Vicryl in the muscle and interrupted subcuticular 4-0 Vicryl to close the skin. Wounds were dressed with steri-strips and dry gauze. The patient tolerated the procedure very well and was taken to the Recovery Room in stable condition. She will return to the office for follow-up in 48 hours for wound recheck. A schedule for expander injections will be arranged at that time.

  

    

Using the above patient report(s), do your own coding and then compare it with our coding recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.
 

 

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to reflect possible coding rules and regulation changes made after the publishing date.