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Assign the CPT procedure codes 1. PROCEDURE(S) PERFORMED: 1. …

Assign the CPT procedure codes

1. PROCEDURE(S) PERFORMED:
1.  Excision of bilateral breast implants.
2.  Right breast capsule excision.

HISTORY: Dolly is a 47-year-old white female who presents for removal of breast implants and a right breast capsular contracture excision. She has had her breast implants in for a little over a year and has had multiple complications including hematomas and malposition over the year. She has had several implants placed in the past. She now is having a good deal of pain, especially on the right side, and she wishes the implants to be removed completely. We discussed various options and decided together to proceed with complete excision of the implants, as well as excision of right-sided capsular contracture.

PROCEDURE: Dolly was brought to the operating room after general anesthetic was administered. Her chest was prepped and draped in the “usual sterile fashion.”
     Surgery was first begun on the right side. Using a 10-blade scalpel the previous implant scar in the inframammary region was excised with a 10-blade scalpel down to subcutaneous tissue. Electrocautery was used to carry the dissection down to the implant capsule. The implant was divided and the saline filled implant was easily removed. Double hooks were used for retraction as an Allis forceps was used to grasp the capsule and electrocautery was used to carefully dissect the capsule free from the surrounding tissue. Once the capsule was completely excised the wound was irrigated with copious saline and careful inspection was made for hemostasis.  Once hemostasis was obtained the deep tissues were reapproximated with interrupted 3-0 Monocryl suture.  The dermis was reapproximated with interrupted and running 3-0 Monocryl subcuticular suture and Dermabond. Attention was then turned to the opposite side using a 10-blade scalpel. A 2.5 cm incision was made through the center portion of the previous implant scar in the inframammary region. This was taken down to the implant capsule with electrocautery. The implant capsule was excised to expose the implant. The implant was punctured and suction was used to remove the saline so the implant could be delivered through the small incision. The wound was carefully inspected hemostasis and irrigated with copious saline. The deep tissues were reapproximated with interrupted 3-0 Monocryl suture.  The epidermis was reapproximated with a running 3-0 Monocryl subcuticular suture and Dermabond. Dressings were placed and she was discharged to recovery in stable condition.
Pathology Report Later Indicated:  Breast and capsule tissue, benign.

2. PROCEDURE(S) PERFORMED:  Right breast open biopsy.

ANESTHESIA: General endotracheal.

INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer.  She also had a highly suspicious lesion on ultrasound in the same area.  An open biopsy was recommended.  Possible definitive treatment with simple mastectomy was also recommended. The patient had a previous lumpectomy, axillary dissection and radiation. The procedure and contingencies were discussed in detail with the patient. Risks and complications including but not limited to infection and hemorrhage were discussed. She understood, accepted and consented.

PROCEDURE: The patient was brought to the operating room and placed in the supine position. After satisfactory induction of general endotracheal anesthesia, the chest, breast and right axilla were prepped and draped in a sterile fashion. The lesion was palpable at approximately 11 o’clock position about 3 cm from the areolar border. An incision was made that would be incorporated into a mastectomy incision. This was carried down through the subcutaneous tissue. A very thin skin flap was raised above the lesion.  The lesion was about 1 to 1.5 cm in size on palpation. This was grasped with a tenaculum, elevated and resected full circumferentially. A small margin of normal tissue was taken. The specimen was then labeled with ties in the appropriate locations and sent to Pathology for analysis for frozen section. Frozen section returned showing atypical cells but a definitive diagnosis of malignancy could not be made.  The patient had previous radiation and there was a lot of fibrosis. This made it somewhat difficult. For this reason, it was elected to close the incision and wait for the permanent sections and final result.  Prior to closing, because the anterior margins were close to this abnormal area, repeat abnormal anterior margins were taken.  After the wound was closed with a deep layer of 3-0 Vicryl and a superficial layer of 5-0 Monocryl, the wound was Steri-Stripped and dressed. The patient was awakened from anesthesia and transferred to recovery in stable condition. She tolerated the procedure well. The estimated blood loss was minimal. Sponge and instrument counts were correct.
Pathology Report Later Indicated: Benign fibrosis tumor.

3. POSTOPERATIVE DIAGNOSIS:  Calcifying epithelioma of Malherbe, forehead, middle aspect.

SURGICAL FINDINGS:  A 0.9-cm-diameter non-ruptured calcifying epithelioma of Malherbe.

SURGICAL PROCEDURE:  Excision of calcifying epithelioma of Malherbe

ANESTHESIA:  General endotracheal anesthesia plus 1 cc of 1% Xylocaine with 1:100,000 epinephrine

DESCRIPTION OF PROCEDURE:  The patient’s forehead was prepped with Betadine scrub and solution and draped in a routine sterile fashion.  I injected 1 cc of 1% Xylocaine with 1:100,000 epinephrine around it and then waited 5 minutes. I made an incision in the forehead and entered the capsule of the epithelioma.  I was then able to dissect the capsule out completely alone with the contents of the sac.  There were no contents of the sac or sac left with the wound. I closed the wound with suture of 5-0 Prolene.  Surgicel and an antibiotic ointment were applied.  The patient tolerated the procedure well and left the operating room in good condition.
     Pathology Report Later Indicated:  Benign skin lesion of the forehead.

4. PREOPERATIVE DIAGNOSIS:  Malignant melanoma, upper chest (1.5 cm)

POSTOPERATIVE DIAGNOSIS:  Same.

PROCEDURE PERFORMED:  Wide excision of malignant melanoma, upper chest.

PROCEDURE:  The upper chest was prepped and draped and cleaned with Betadine solution.  A margin of 2 cm laterally and medially around the lesion site was taken.  The incision was carried down to the muscle fascia, which was included in the specimen.  Bleeding was controlled by electrocautery, and we closed the defect with a running subcuticular 4-0 undyed Vicryl using layered closure.  Steri-Strips and a sterile bandage were applied.  He tolerated this well. 
     Pathology Report Later Indicated: Malignant melanoma.

5.  PROCEDURE PERFORMED:  Excision of plexiform fibrous histiocytic tumor of the right shoulder.

ANESTHESIA:  General endotracheal with approximately 20 cc of tumescent solution prepared by adding to 1 L of Ringer’s lactate, 25 cc 2% Xylocaine, 1 cc of 1:100,000 epinephrine, and 3 cc of 8.4 sodium bicarbonate.

DESCRIPTION OF PROCEDURE:  The patient was intubated.  The area of the right shoulder was prepped with Betadine scrub and solution and draped in a routine sterile fashion.  An incision was made 3 cm and carried down to the fascia of the muscle.  The skin portion of the lesion was removed, and the fascia and a portion of the muscle were removed secondarily.  The lesion measured 3.5 cm at the widest point.  Bleeding was electrocoagulated, and  #7 Jackson-Pratt drain was inserted in the depth of the wound.  The wound was closed with interrupted 0 Monocryl for the deep fascia layer and subcuticular 4-0 Monocryl using a few vertical mattress sutures of 3-0 Monocryl.  Steri-Strips and Kerlix fluffs plus Elastoplast were applied.  The patient tolerated the procedure well and left the operating room in good condition. 
     Pathology Report Later Indicated:  Benign lesion.

6.  POSTOPERATIVE DIAGNOSIS:  10 cm lipoma, right thigh

PROCEDURE PERFORMED:  Excision of 10 cm right thigh lipoma

INDICATIONS:  Tyra Olsen is a very pleasant 32-year-old female, who presented with a large lipoma of her right thigh.  She wants to have this resected.  She understands the surgery and the risks of bleeding, infection, postoperative fluid collections and wishes to proceed.

PROCEDURE:  The patient was brought to the operating room, given IV sedation and then prepped and draped with Betadine solution.  The area was then anesthetized with a total of 40 cc of 0.5% Sensorcaine with epinephrine solution.  A skin incision was made with a #15 blade, and the lipoma was resected sharply down into the soft tissue.  Bleeding was controlled with the electrocautery, and then the subcutaneous was closed and then the skin was closed with subcuticular 4-0 undyed Vicryl.  Steri-Strips and a sterile bandage were applied.  She tolerated this well and was discharged home.
     Pathology Report Later Indicated: Lipoma, benign, thigh, soft tissue.

7.  OPERATION PERFORMED: Biopsy of mass, right axilla.

PRELIMINARY NOTE: This patient had a mastectomy  six years ago and had positive nodes at that time. Recently, she presented with a fixed mass in the right axilla, and after a good deal of discussion, she decided to have a biopsy done. We did a true cut needle biopsy and obtained a diagnosis of metastatic cancer. The patient was seen by Dr. White, and he wanted tissue so that HER-2/neu receptors could be determined in order to plan out her chemotherapy; so we are taking her back to the operating room to get an adequate wedge of tissue for HER-2/neu receptors.

OPERATIVE NOTE: With the patient under general anesthesia, the right axilla was prepped and draped in a sterile manner. A curved incision was made over the palpated mass.  Sharp dissection was carried down through the subcutaneous tissue, and we encountered a fixed mass, this was fixed to the underlying muscle, but was not fixed to the chest wall.
     Using the electrocautery, we resected around the mass to free it up a little bit. We were able to remove the upper portion of the mass using the electrocautery for hemostasis. We had a good specimen of tumor by gross appearance that we submitted to the pathologist for appropriate studies. Hemostasis was restored with the electrocautery. The subcutaneous tissue was reapproximated using 2-0 chromic and then the skin was closed using 4-0 Vicryl in a subcuticular manner. Steri-Strips were applied. The patient tolerated the procedure well and was discharged from the operating room in stable condition. At the end of the procedure, all sponges and instruments were accounted for. 
     Pathology Report Later Indicated: Metastatic neoplasm, axilla, and breast primary.

8. SURGICAL FINDINGS: 3 x 1 cm elevated scar right parietal region of scalp.

SURGICAL PROCEDURE: Excision scar of scalp.

ANESTHESIA: General endotracheal anesthesia, plus 2 cc of 1% Xylocaine and 1:100,000 epinephrine.

PROCEDURE: The scalp was prepped with Betadine scrub and solution, draped in the routine sterile fashion. The lesion was anesthetized with 2 cc of 1% Xylocaine with 1:100,000 epinephrine, mostly for the epinephrine effect. After a wait of four minutes the lesion was excised, bleeding was electrocoagulated; the wound was closed with vertical mattress sutures of 3-0 Prolene.  Surgicel and antibiotic ointment were applied. The patient tolerated the procedure well and left the operating room in good condition. 
Pathology Report Later Indicated: Benign scar tissue of skin.

9. PROCEDURE PERFORMED: Pilonidal cystectomy.

HISTORY: This gentleman either has a sebaceous cyst or a complex pilonidal sinus with a fistula toward the left. It was elected to probe the area and do what is necessary.

PROCEDURE: The patient was given general anesthetic. He was placed in the prone jackknife position and his buttocks were taped apart. He was prepped and draped in this position. I put a lacrimal probe in the lateral site off midline toward the left and it went right toward the midline. It went right toward the pilonidal sinus that I saw in the office. I then put a probe in the pilonidal sinus and they met. I then marked the area of pilonidal cystectomy but I included the whole of the pilonidal fistula going off to the left and then I resected the whole pilonidal sinus in the midline and the fistula to the left of midline, making sure I took all of the granulation tissue out and the whole tract. I obtained excellent hemostasis with cautery and then packed with 1/2-inch NuGauze that was sitting in Xylocaine with epinephrine. Gauze and tape were applied. The patient tolerated this well and went to the recovery room in good condition.
Pathology Report Later Indicated: Benign pilonidal cystic tissue.

10.  PROCEDURES PERFORMED:
1. Excision of sacral ulcer.
2. Excision of coccyx.

SURGICAL FINDINGS: There was about a 4 cm deep ulcer that went all the way down to the coccyx. The coccyx was separated from the sacrum and had very sclerotic bone in it.  It was very vascular around the coccyx.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 150 cc.

DRAINS: #10 Jackson-Pratt.

PROCEDURE: The patient was intubated and turned to the prone position. The buttocks were prepped with Betadine scrub and solution and draped in routine sterile fashion. The ulcer was excised elliptically by following a hemostat to the bottom of the wound which ended in the lower end of the sacrum/upper end of the coccyx. We took a piece of the coccyx and placed it in a culture tube. I then removed the coccyx which was quite vascular, clamping bleeders with 2-0 Vicryl and putting in one stick tie of 2-0 Vicryl. The coccyx was removed and submitted for specimen. A piece of Gelfoam with some topical thrombin spray was placed in the depth of the wound, and the wound was closed in two layers with interrupted 0 Monocryl for the deepest fascial layer over the drain and over the bed from which the coccyx had been dissected. We also closed the skin with #2 Protene. The drain was sutured in with 0 Monocryl.  Dressing consisted of Kerlix fluffs and Elastoplast.  The patient tolerated the procedure well and left the operating room in good condition. 
Pathology Report Later Indicated: Benign ulcerated tissue.

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