Question

Loren White, M.D.

PREOPERATIVE DIAGNOSIS: Mass, right axilla, history of breast cancer.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION PERFORMED: Biopsy of mass, right axilla.

PRELIMINARY NOTE: This patient had a mastectomy six years ago and had positive nodes at that time. Recently, she presented with a fixed mass in the right axilla, and after a good deal of discussion, she decided to have a biopsy done. We did a true cut needle biopsy and obtained a diagnosis of metastatic cancer. The patient was seen by Dr. White, and he wanted tissue so that HER-2/neu receptors could be determined in order to plan out her chemotherapy; so we are taking her back to the operating room to get an adequate wedge of tissue for HER-2/neu receptors.

OPERATIVE NOTE: With the patient under general anesthesia, the right axilla was prepped and draped in a sterile manner. A curved incision was made over the palpated mass. Sharp dissection was carried down through the subcutaneous tissue, and we encountered a fixed mass, this was fixed to the underlying muscle, but was not fixed to the chest wall.
     Using the electrocautery, we resected around the mass to free it up a little bit. We were able to remove the upper portion of the mass using the electrocautery for hemostasis. We had a good specimen of tumor by gross appearance that we submitted to the pathologist for appropriate studies. Hemostasis was restored with the electrocautery. The subcutaneous tissue was reapproximated using 2-0 chromic and then the skin was closed using 4-0 Vicryl in a subcuticular manner. Steri-Strips were applied. The patient tolerated the procedure well and was discharged from the operating room in stable condition. At the end of the procedure, all sponges and instruments were accounted for.
     Pathology Report Later Indicated: Metastatic neoplasm, axilla, and breast primary.

ICD 10, CPT, HCPCS codes needed

Answer 1

ICD -10 CM code is the international classification of disease ,tenth version .It is used by the healthcare workers to denote a diagnosis and clinical manifestation . It is used by the insurance companies for reimbursement purpose .

ICD code for Metastatic neoplasm ,axilla and breast primary is C50.611

CPT code is current procedural terminogy , it is used by the health care workers to denote the procedures and insurance companies use this code for reimbursement purposes .

CPT code for biopsy of mass, right axilla is 38500