Please review the 2 operative reports given and audit the coding. Please write i

Question

Please review the 2 operative reports given and audit the coding. Please write if the codes are correct or if a different code should be used. Also if a modifier is missing please add it to the code.

If everything is correct please write down that you agree with the codes.

Case #1

Indications: Left breast Mass

The patient was prepped and draped in the usual sterile fashion. 1% Xylocaine was injected around the areolar margin from the 4-8o’clock position. A skin incision was made, deepened down to the soft tissue using sharp dissection. Hemostasis was obtained with electrocautery. The dissection was deepened in to the breast where the mass was identified, grasped and elevated into the incision and dissected circumferentially using sharp blunt dissection. The specimen was removed and sent to pathology. The wound was irrigated, infiltrated with Marcaine 0.25% abd ckosed using 3-0 Dexon and 4-0 Maxon in running fashion. Sterile dressing was applied. The patient tolerated the procedure well.

19120-LT

Case #2

Indications: Microcalcifications right breast times two

The patient had a mammogram and localization needles were inserted. The patient was then scheduled for removal of the lesions.

The patient was placed in the supine position with the left arm extended in a 90 degree angle. The left mammary area was prepped with Betadine solution with care so the needles would not be displaced. A transverse incision at 3 o’clock was performed in the left breast, the skin and subcutaneous tissues were divided and the needle was identified. The lesion identified by the first Kopans needle was identified and a cylinder of breast tissue was resected. Then a new incision was performed at 6 o’clock were the other needle had been placed. The procedure was repeated and the lesion, a cylinder of breast tissue with the needle was also removed. The breast tissue was then re-approximated with interrupted 3-0 Vicryl and the skin was closed with 4-0 Vicryl stitches. The patient tolerated the procedure well and was transferred to the recovery room in good condition.

The pathologist confirmed the two lesions had the needle localization in place and corresponded to the calcificated tissue.

Codes:

19281 Lt and 19282 LT

Explanation / Answer

Code no : 19120 Lt

Mirror image procedures on a single structure. for example ; a surgery on a spine means it's a single structure but we do a mirror image PROCEDURE like ( make incision on right side means left side also do that )

Code no :19281 Lt

Placement of breast localization devices( e.g.. clips , metallic pellet , wire or needles)

Code no ; 19282 Lt

Each additional lesions including mammographic guidance.

Related Questions

Navigate

• Browse (All)
• Browse P
• Subjects

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.