Question

                                                     

   Q: Need help with this outpatient case to code diagnosis and CPT/HCPCS codes                                        

                                                        Case: 410057, Female, Age-57             

                                                             Department of Surgery

                                                       Interval History and Physical Note

Admission Date and Time: 3/19/2014 5:57 AM

Preoperative Diagnosis: invasive ductal carcinoma of the right breast

Pertinent laboratory tests: hct 44, Cr 0.8, INR 1.0

Procedure: Right segmental mastectomy with sentinel lymph node biopsy, and breast reconstruction

Surgeon:

Specific counseling: given in clinic

H&P documentation: I have examined the patient and there have been no interval changes in the

patient's medical condition since the H&P was done.

3/19/20146:56 AM

Cancer Follow Up

DIAGNOSIS: Newly diagnosed Stage Ila right breast invasive ductal carcinoma -ER/PR 99% Her 2 Neu

negative per IHC

DATE DIAGNOSIS (MONTH/YEAR): 3/2014

DATE OF SURGERY (MONTH/YEAR): Scheduled

HISTORY: This 57 y.o. y/o woman returns for surgical planning. Ms. initially presented with a screened detected right breast invasive ductal carcinoma, tumor marker profile pending at that time. She denied any palpable masses, nipple discharge, skin changes, or axillary adenopathy. Due to breast density it was recommended that she undergo breast MRI. She presents today for surgical planning. She has no new complaints. She has no other new medical problems and has not started new medications. Her current medication(s) are: has a current medication list which includes the following prescription(s): calcium carbonate and levothyroxine.

PHYSICAL EXAMINATION:

This is a well-nourished, alert and oriented woman. Both nipples are everted without discharge. Due to breast density there is no discrete dominant mass palpable. There is no focal nodularity or on either side. She does have well healed reduction mammoplasty scars on both breasts. The abdomen is soft, flat and nontender, without palpable masses or organomegaly.

IMAGING Findings: Right breast: Centered directly posterior to the nipple (12 o'clock, Zone 2/3) in the right breast there is an enhancing, irregular mass that measures 2.8 (AP) x 1.5 cm in axial dimensions. The mass measures 1.8 cm in cranial caudal dimension. The mass is located

approximately 5.2 cm posterior to the nipple and is 3 cm deep to the superior skin surface on the sagittal views. There is a background of fibrocystic change throughout the right breast with scattered nonspecific foci of enhancement. There are no suspicious right axillary lymph nodes.

Left breast: There are scattered fibrocystic changes, with scattered nonspecific foci of enhancement throughout the left breast, without enhancing mass lesion. There are no suspicious left axillary lymph nodes.

Impression:

Right breast: Enhancing mass in the right breast as detailed above compatible with the patient's biopsy-proven invasive ductal carcinoma. A second site of disease within the right breast is not identified. There are no suspicious right axillary lymph nodes on MR imaging Background fibrocystic change.

Left breast: Scattered fibrocystic change in the left breast without suspicious mass lesion.

Recommendation: Continued management by the clinical breast team as previously

scheduled.

Note: A normal 05,does not exclude the presence of DCIS,invasive lobular carcinoma or

Cancers less than 3 millimeters in size. 05,does not replace mammography and should be used as

An adjunct to annual mammography and physical exam as necessary.

BI -RADS:6

Impression:Newly diagnosed stage IIa right breast invasive ductal carcinoma (535 99% Her 2 Neu

negative per IHC.

Recommendations: I reviewed the natural history and evolution of breast cancer were discussed with Ms. and her husband, including the difference between in-situ and invasive carcinoma, and the distinction between local and systemic disease and local and systemic therapy. For

local treatment options, explained the risks and benefits of breast conservation and mastectomy with or without reconstruction, including the fact that survival rates are equal with these two approaches. , if breast conservation is elected, ,explained the need for free margins, the possibility of re-excision to achieve free margins, and the need for post-operative radiotherapy. ,explained that based on her MRI she is a breast conservation candidate. ,did discuss with her the role of oncoplastic surgery to assist with cosmetic outcomes post radiation therapy. ,explained that due to her tumor size she will require a fairly large excision that will leave her with a void of breast tissue. ,explained that Dr. will discuss with her options for both therapeutic mammoplasty at the time of surgery as well as as reconstruction post mastectomy if she were to elect to undergo mastectomy. She explained that she wanted to undergo breast conservation with oncoplastic approach. We discussed both immediate and delayed therapeutic mammoplasty in regards to margin positivity. She understands that if she wanted to undergo immediate oncoplastic treatment that a mastectomy may be required if her margins return positive.

The approach to nodal staging was also re-described, including the technique, risks and benefits of Sentinel node biopsy, the possible need for axillary dissection, and the long-term sequelae of this procedure. With regard to systemic therapy, final recommendation will be made following receipt of final Pathology post-op, but, I outlined the possibility of endocrine therapy and chemotherapy depending on her pathologic stage. Following this discussion, where all of the patient's questions were answered, we agreed to proceed with Ultrasound guided segmental mastectomy, SLNB, with therapeutic mammoplasty.

This encounter lasted 45 minutes and> 50%was devoted to a discussion of management options.

She has been encouraged to contact the office with any questions/concerns prior to her next appointment.

MD

Department of Surgery: I, saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the note.

Plan: Right wire localized segmental mastectomy, sentinel lymph node biopsy, and possible

reconstruction with Dr.

Department of Surgery

Revision History ...

Date/Time User Action

Related encounter: Admission(discharged) from 3/19/2014

DATE OFSERVICE: 03/19/2014

PREOPERATIVEDIAGNOSIS: Right breast mass.

POSTOPERATIVEDIAGNOSIS: Right breast mass.

OPERATIONPERFORMED: Local flap closure of the right breast defect.

SURGEON: . MD

ASSISTANTSURGEON: MD

ANESTHESIA: General

IVFLUIDS: 1400ml.

ESTIMATEDBLOODLOSS: 10ml.

FINDINGS: Excision of right breast mass from the 11 o’clock position .

SPECIMENS: Right breast mass; mastectomy skin.

DRAINS: None.

COMPLICATIONS: None.

DISPOSITION: Stable to the Day Surgery Unit and extubated.

INDICATIONSFORPROCEDURE: The patient is a 57-year old female with an extensive surgical history involving her bilateral breast including prior mastopexies as well as breast augmentation. The patient presented to my clinic with a newly diagnosed right breast mass to discuss possible breast conservation therapy and therapeutic mammoplasty. The patient stated that she had a strong interest for a reduction procedure. ,it was explained to her, at that time, that given the prior surgeries and implant she would be at very high risk for therapeutic mammoplasty and may require a nipple graft, and also may develop fat necrosis over the inferior pedicle, We quoted her at that time a 50% risk of the above occurring . We also discussed potentially doing no reduction following excision of the tumor based on intraoperative findings. Possible risks were discussed with the patient including bleeding, infection, scarring, asymmetry, change in sensation, contour deformity, sensation, contour deformity, extensive fat necrosis and need for eventual mastectomy. The patient consented to the above.

DESCRIPTIONOFPROCEDURE: The patient was brought to the Preoperative area. The patient was marked for an inferior Pediclw Wise pattern reduction. Of note, the nipple was set at 22 cm . In this manner, a standard wise pattern was then drawn. The patient was then brought to the operating Room. The patient was placed supine on the operating room table. A full stop time-out was performed. Ancef ,IV antibiotics were given within 30 minutes of incision. The chest was prepped and draped in the standard fashion.

The procedure began with a sentinel lymph node biopsy, per Dr. Please review her operative notes for this portion of the procedure. We then decided to begin with a lateral extension of the Wise pattern to approach the mass. ,assisted Dr. . _ in this approach using the lateral extension of the Wise pattern. The mass was then localized, per Dr. , and excised down to the chest wall. Of note, we did enter the patient's prior capsule at this time and it became clear that the patient's capsule extended throughout the inferomedial aspect of the breast above the pectoralis muscle. At this time, it begin evident that a superomedial pedicle would not be feasible ,then stepped out and discussed this with the patient's husband and explained our intraoperative findings. He agreed with proceeding with primary closure. For that reason, undermined the breast tissues cephalad above the pectoralis muscle as well as freeing the breast tissue from the overlying dermis ,then backcut the breast parenchyma creating a flap measuring 6 x 6 x 6 ern and rotated the breast tissue into the defect and closed this using 2-0 dyed PDS. Prior to doing this, did irrigate the pocket with lrricept solution and obtained meticulous hemostasis. ,then de-epithelialized an area of the lateral breast tissues to provide a minor left laterally to help with the coning of the breast. The skin was then closed primarily. Similarly, the sentinel node site was irrigated and closed in multiple layers using 3-0 and 4-0 Monocryl. The sites were dressed with bacitracin and Xeroform, dry sterile dressings, and Tegaderm. The patient was placed into a surgical bra. Fluffs were placed. The patient tolerated the procedure well without any complications. All instrument, sponge and lap counts were correct at the end of the case. The patient was transferred to the PACU in stable condition, extubated. ,was present for the entire plastic surgery portion of this procedure including the opening and closing.

Related encounter:Admission(Discharge)

Patient awake and alert. Vital signs stable and at baseline. Patient reports pain 2/10. Tolerating po intake without n/v. After care teaching and discharge instructions reviewed with patient and husband. Understanding verbalized. Mastectomy bra in place. Clean, dry and intact. Patient transferred via wheelchair to car.

Department of Radiology

Division of Breast ,Imaging

Procedure Note

PRE-OP Diagnosis: right breast CA

POST -OP Diagnosis: ame

Procedure: US guided right breast wire localization

TYPE of Anesthesia/ Sedation: Lidocaine 1 %without epinephrine

Surgeon/ Proceduralist(S):
Findings: Dense breast tissue, dense mass. Difficult to get needle into mass. 19.5 cm wire

with 15.5 cm out, 4 cm in breast. Wire tip position antero-lateral to clip, which is extends 17

mm medial to clip and 2.5 cm posterior to clip. Positioned discussed with at the time of placement. Position is adequate for her needs.

Complications: none

Disposition of specimen: n/a

I was present for and participated for the entire procedure. A resident participated in this

Answer 1

The CPT code for segmental mastectomy is 19301, for sentinel lymph node biopsy is 38530 for internal mammary and for breast reconstruction with flaps is 19364 .