LOCATION: Inpatient, Hospital
PATIENT: Charlene Tipton
SURGEON: Loren White, M.D.
PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass.
PROCEDURE(S) PERFORMED: Right breast open biopsy.
ANESTHESIA: General endotracheal.
INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer. She also had a highly suspicious lesion on ultrasound in the same area. An open biopsy was recommended. Possible definitive treatment with simple mastectomy was also recommended. The patient had a previous lumpectomy, axillary dissection and radiation. The procedure and contingencies were discussed in detail with the patient. Risks and complications including but not limited to infection and hemorrhage were discussed. She understood, accepted and consented.
PROCEDURE: The patient was brought to the operating room and
placed in the supine position. After satisfactory induction of
general endotracheal anesthesia, the chest, breast and right axilla
were prepped and draped in a sterile fashion. The lesion was
palpable at approximately 11 o'clock position about 3 cm from the
areolar border. An incision was made that would be incorporated
into a mastectomy incision. This was carried down through the
subcutaneous tissue. A very thin skin flap was raised above the
lesion. The lesion was about 1 to 1.5 cm in size on palpation. This
was grasped with a tenaculum, elevated and resected full
circumferentially. A small margin of normal tissue was taken. The
specimen was then labeled with ties in the appropriate locations
and sent to Pathology for analysis for frozen section. Frozen
section returned showing atypical cells but a definitive diagnosis
of malignancy could not be made. The patient had previous radiation
and there was a lot of fibrosis. This made it somewhat difficult.
For this reason, it was elected to close the incision and wait for
the permanent sections and final result. Prior to closing, because
the anterior margins were close to this abnormal area, repeat
abnormal anterior margins were taken. After the wound was closed
with a deep layer of 3-0 Vicryl and a superficial layer of 5-0
Monocryl, the wound was Steri-Stripped and dressed. The patient was
awakened from anesthesia and transferred to recovery in stable
condition. She tolerated the procedure well. The estimated blood
loss was minimal. Sponge and instrument counts were correct.
Pathology Report Later Indicated: Benign fibrosis tumor.
What are the CPT, ICD-10-CM and HCPCS codes?
CPT AND ICD 10 CM CODE RIGHT BREAST MASS IS 19120 AND N63.20 RESPECTIVE.
CPT AND ICD 10 CM CODE FOR BENINGN FIBROSIS TUMOR IN BREAST IS D24.1.
HCPCS CODE FOR RIGHT BREAST OPEN BIOPSY IS( 19282, 19284, 19286AND 19288).
LOCATION: Inpatient, Hospital PATIENT: Charlene Tipton SURGEON: Loren White, M.D. PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass. PROCEDURE(S)...
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