LOCATION: Inpatient, Hospital


LOCATION: Inpatient, Hospital

PATIENT: Charlene Tipton

SURGEON: Loren White, M.D.


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.

What are the CPT, ICD-10-CM and HCPCS codes?

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