Please help. Patient had bilateral mastectomy 2 weeks ago. Positive margin on skin. Patient taken back for additional skin excision. Doctor wants to code 19301, but the breast is gone. I’m questioning whether this should be a malignant lesion excision.

11606 -58
12043-58
10140

Any help would be greatly appreciated!

Thanks,

Kelly C, CPC

Indication for Surgery
left breast cancer, positive skin margin

Preoperative Diagnosis
same

Postoperative Diagnosis
same

Operation
excision left breast skin
drainage of hematoma

Estimated Blood Loss
min

Urine Output
na

Findings
The PSI-15 for accidental puncture or laceration is: none
The frozen section: none
Important intraoperative findings are as follows: old blood evacuated, more skin removed from the lateral skin flaps and reclosed
DISPOSITION OF PATIENT IS: pacu

Specimen(s)
lateral skin new stitch on margin
inferior/lateral skin new stitch on margin

Complications
none

Technique
After informed consent was obtained patient was brought to operating room and given preoperative antibiotics and IV sedation with anesthesia. I accessed the right chest port. I removed the steris and bilateral JP drains. The left breast and axilla was prepped and draped with Chloraprep in the usual fashion and allowed the dry 3 minutes before draping. I removed the lateral skin ellipse 8 x 3 cm portion, marked. Then took another 2 cm margin on the inferior skin flap. Good hemostasis was insured and the area washed out copiously. I then placed 10F JP drain into the space from the axilla and sutured it in with 3-0 nylon. The skin was reapproximated with deep 2-0 vicryl and 4-0 monocryl sutures. Dermabond applied, sterile dressings placed, and patient was taken to recovery room in stable condition.