louise Posted Mon 08th of April, 2019 21:57:39 PM
Examination of the left breast mound revealed a full-thickness wound dehiscence and left breast inframammary fold area. There was necrotic breast tissue present. There was no exposed implant but there was swelling on the left breast. Subsequently A 7 cm inframammary fold incision was made on left breast wound dehiscence area. This incision was carried down to subcutaneous tissue with scalpel. Bovie cautery was used to divide this tissue and carefully approached acellular dermal matrix. This was divided and pocket was entered on left side. There was 100 cc of serous fluid which was evacuated. Fluid was sent off to microbiology for further workup. Implant was removed which was intact. Gross examination of pocket revealed good incorporation of acellular dermal matrix with no obvious signs of gross infection. Subsequently pocket was thoroughly irrigated with Betadine and triple antibiotic irrigation. A #10 drain was placed in the left breast pocket and brought out via separate stab incision and lateral chest area and secured to skin with 4-0 nylon suture. 10 cc of quarter percent Marcaine with 1 1000 epinephrine was injected in left breast pocket. Left breast primary fold incision was closed in several layers with 2-0 PDS suture and dermis was reapproximated 3-0 Monocryl suture. skin was reapproximated with 4-0 Monocryl suture.
She also had a 4 x 3 cm nonhealing wound on her left mid breast flap. This was excised in a full-thickness fashion with 0.5 cm margin circumferentially. Wound was closed in several layers with 2-0 PDS suture.
SuperCoder Answered Tue 09th of April, 2019 09:39:29 AM
The physician has performed procedure for full-thickness wound dehiscence and breast inframammary fold area. Breast revision is performed to improve unacceptable cosmetic appearance or other complication. As per the provided documentation, the appropriate CPT code will be 19380.