Preoperative Diagnosis: Postoperative Diagnosis: Same (pending pathology)
Preoperative Diagnosis: Postoperative Diagnosis: Same (pending pathology) Operation: Excision of right breast mass, intermediate wound closure—4 cm Surgeon: Roweena L. Macomba, MD Assistant: None Anesthesiologist: Terence Abnernathy, MD Anesthesia: MAC/1% lidocaine diluted 50% with bicarbonate (10 cc) Specimens: Breast tissue HISTORY: This is a 51-year-old female admitted to the minor surgery suite for excision of a 1-cm palpable nodule in the superficial aspect of the right breast in the 12 o’clock axis near the periphery. The indications, alternatives, and possible complications were reviewed and consent was obtained. PROCEDURE: With the patient in the supine position, the area in was prepped and draped in the usual sterile fashion using Betadine. After adequate IV sedation, 1% lidocaine without epinephrine was used to infiltrate the soft tissues at that level to create a field block. An elliptical incision was made about the lesion itself, considering its intimate association with the overlying skin. The 4-cm incision was deepened into the subcutaneous space. The mass was excised in its entirety with a rim of normal appearing breast, fat, and surrounding skin. Adequate hemostasis was secured within the depths of the wound. The wound was closed in layers. The deeper breast tissue was approximated using interrupted 3-0 chromic sutures. The subcuticular layer was approximated using interrupted 4-0 Biosyn sutures. The skin edges were closed using 4-0 Vicryl in the subcuticular space in a continuous fashion. Mastisol and Steri-Strips were applied. A dressing was applied. The procedure was terminated. Needle, sponge, and instrument counts were correct. Estimated blood loss was minimal. DISPOSITION: The patient tolerated the procedure and was discharged from the minor operating department in satisfactory condition. Roweena L. Macomba, MD RLM/mg D: 12/15/18 12:55:01 T: 12/18/18 09:50:16 ————————————————————————————————————————————– One diagnosis code When you follow the logic for the breast mass, 3M takes you to a code for the Unspecified lump in Unspecified breast, but this is incorrect because we know the location of the tumor. The laterality of the breast was documented as well as the specific location of the tumor. The specific location is tricky to find, but it’s there. It’s not worded exactly like the codebook. Google “clock face orientation breast” and click on the first result to learn more. In 3M, when you get to the end screen, click on the Codebook option for the unspecified lump in the diagnosis list. It will take you to the codebook, so you can review the codes for the specific location and pick the one you want. When you find the right code in 3M, be sure to click into the Coding Clinic to learn more about it. One CPT code The coding path in 3M is weird for this one. Start with Excision as the keyword and then Spell the site. Connect wants a code that says the mass was identified by a radiological marker, but we don’t have that in the documentation. The Op note would usually say something about identifying the marker (or “clip”) and excising it with the mass. Surgeons always make sure they document the presence of markers in case someone sues them for accidentally leaving one in. One PCS code When you get to the end summary screen be sure to click on the Coding Clinic that goes with it. One anesthesia code with one modifier.
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