Help! I need CPT and ICD-10 codes for this scenario:
LOCATION: Inpatient, Hospital PATIENT: Dolly Grande SURGEON:Loren White, M.D. PREOPERATIVE DIAGNOSIS: Chronic pain in bothbreasts and right breast capsular contracture. POSTOPERATIVEDIAGNOSIS: Pain due to presence of bilateral saline breast implantsand right breast capsular contracture. PROCEDURE(S) PERFORMED: 1.Excision of bilateral breast implants. 2. Right breast capsuleexcision. HISTORY: Dolly is a 47-year-old white female who presentsfor removal of breast implants and a right breast capsularcontracture excision. She has had her breast implants in for alittle over a year and has had multiple complications includinghematomas and malposition over the year. She has had severalimplants placed in the past. She now is having a good deal of pain,especially on the right side, and she wishes the implants to beremoved completely. We discussed various options and decidedtogether to proceed with complete excision of the implants, as wellas excision of right-sided capsular contracture. PROCEDURE: Dollywas brought to the operating room after general anesthetic wasadministered. Her chest was prepped and draped in the “usualsterile fashion.” Surgery was first begun on the right side. Usinga 10-blade scalpel the previous implant scar in the inframammaryregion was excised with a 10-blade scalpel down to subcutaneoustissue. Electrocautery was used to carry the dissection down to theimplant capsule. The implant was divided and the saline filledimplant was easily removed. Double hooks were used for retractionas an Allis forceps was used to grasp the capsule andelectrocautery was used to carefully dissect the capsule free fromthe surrounding tissue. Once the capsule was completely excised thewound was irrigated with copious saline and careful inspection wasmade for hemostasis. Once hemostasis was obtained the deep tissueswere reapproximated with interrupted 3-0 Monocryl suture. Thedermis was reapproximated with interrupted and running 3-0 Monocrylsubcuticular suture and Dermabond. Attention was then turned to theopposite side using a 10-blade scalpel. A 2.5 cm incision was madethrough the center portion of the previous implant scar in theinframammary region. This was taken down to the implant capsulewith electrocautery. The implant capsule was excised to expose theimplant. The implant was punctured and suction was used to removethe saline so the implant could be delivered through the smallincision. The wound was carefully inspected hemostasis andirrigated with copious saline. The deep tissues were reapproximatedwith interrupted 3-0 Monocryl suture. The epidermis wasreapproximated with a running 3-0 Monocryl subcuticular suture andDermabond. Dressings were placed and she was discharged to recoveryin stable condition. Pathology Report Later Indicated: Breast andcapsule tissue, benign.
