Annette Posted Fri 16th of July, 2010 03:21:25 AM
im thinking 19371 & 19340, don't think its 19330 as the silicone material is not outside the capsule, and i know the report mentions capsulectomy but i've heard it said somewhere that there needs to be an indication of contracture/tightness.....
DX: rupture of right silicone breast implant secondary to trauma
skin incision was made. subcutaneous tissue was separated and the capsule rim of the implant was noted. the patient had a capsule gently entered with electracautery to avoid any damage to the implant itself. Once this was deon, the patient noted on the anterior surface of the implant to be totally intact however. The posterior surface there was a tear and there was free floating silicone in the actual pocket. After immediate removal of the implant was achieved a capsular resection was performed. with the capsule removed, the patient although there was minimal bleeding and the casulectomy pocket was reirrigated again with peroxide betadine saline The patient then had a silicone breast sizer inserted to assure that the 400 cc implant, which was done outside of this country and produced by different company would give a perfect result in symmetry to her breast. a 400cc Allergan implant was utiliaed and it was noted once this inserted that the patient had developed symmetry.
SuperCoder Answered Fri 16th of July, 2010 07:18:19 AM
Yes as per the Op notes you are correct with the codes 19371 and 19340. Cpt 19330, needs some extra documentations, work done and extent of implant material leaked.