Assignment Help| Preoperative Diagnosis: Abnormal mammogram, left breast
Preoperative Diagnosis: Abnormal mammogram, left breast
Postoperative Diagnosis: Same
The patient is a 61-year-old G3, P3 female with a family history of positive carcinoma of the breast. She underwent a screening mammogram in the spring of this year that demonstrated a localized density in the subareolar tissue of the left breast. Physical examination demonstrated no palpable abnormality in the area.
The patient was brought to the OR after undergoing placement of a hook wire localizing needle in the mammography suite by the radiologist. She was placed on the operating table in a supine position. After ensuring an adequate level of conscious sedation, her left breast and chest wall were prepped and draped in the sterile fashion. A needle/wire complex was protruding from the left breast approximately 2 centimeters above the nipple.
The skin surrounding the needle in the breast tissue in the subareolar area was infiltrated with 1% Xylocaine to achieve local anesthesia. A 5-cm incision was made around the localizing wire. Small superior and inferior skin flaps were elevated, exposing the underlying subcutaneous fat. Dissection with electrocautery was begun into the breast about the wire. The needle wire complex was grasped using Allis clamps and drawn into the operative wound. The breast tissue and subcutaneous fat surrounding the needle were excised in this fashion until all the tissue surrounding the needle/wire complex was excised. The specimen was then forwarded to the radiology suite for specimen mammography.
As the specimen mammogram was being obtained, the wound was examined for hemostasis, which was thought to be complete. The deeper breast tissues were closed using interrupted 3-0 Vicryl figure-of-8 sutures. Subcutaneous tissues were approximated in a similar fashion. The wound was irrigated and again examined for hemostasis, which was thought to be complete. The skin was closed using running 5-0 Maxon subcuticular suture. The wound was washed and dried and sterile dressings applied. The operative field was not disturbed until call was received from the radiology suite indicating that the specimen contained the area of interest identified on the patient’s original mammogram. At this point, the patient was transferred to the recovery area in stable condition.
Assign only CPT surgical codes (no E/M codes) and append any applicable modifiers.