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Scenario Week of June 29, 2011:
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Description of Procedure: The patient was seen and identified in the preoperative holding area. All questions were answered. IV was started by anesthesia, then the patient was taken to the operating room where she was placed comfortably in the supine position while awake. Venodynes were placed and started. Sedation was begun. She was given 1 gm of cefazolin.

The left breast had a desmoid tumor which was excised multiple times; however, all margins were positive including pectoralis muscle. She had an implant placed years ago, and the implant is retropectoral according to the patient. This procedure is for completion mastectomy of the left breast as well as implant removal and placement of new tissue expander.

The previous surgeries were performed through a radial incision that extends from 8:00 to 11:00 about 4 cm circumferentially from the nipple. However, I decided that this would not be a safe place to reenter and tried to obtain clear tissue all the way over to the axillary tail. Therefore, upon discussion with the assistant surgeon we decided to make an inframammary incision from approximately 7:00 to 4:00. The 10 cm incision was created in the inframammary fold after local anesthetic mixture of .25% Marcaine and 0.5% Marcaine was mixed with a sterile injectable normal saline in 500 mL volume. This mix was injected along the area of the dissection over the whole breast in the subcutaneous plane.

Once this was done, a #10 blade was used to make an inframammary incision, and the incision was carried down through into the dermis. Subcutaneous tissue was divided by electrocautery and I encountered the capsule of the implant at the inferior border of the pectoralis muscle. After dividing some of the muscle fibers, the implant capsule was carefully entered and the implant was removed. On careful inspection of the implant there was some internal floating debris that looked cottony; therefore, we sent the specimen with the requests that the internal debris be cultured and analyzed.

Once the implant was out, I began to create the anterior flap of the mastectomy. Retraction was achieved with rakes when the dissection was superficial and we progressed using medium, then large Richardson, and then finally lighted retractor. The plane of dissection was extremely difficult as the incision was kept relatively small. However, the difficulty was due to the previous surgical scarring, especially under the previous radial incision. The previous radial incision was approached using sharp dissection with facelift scissors and we stayed above the point where the capsule of the implant was encountered, although there was almost no tissue between that and the undersurface of the scar. Using careful retraction with the lighted retractor, as well as alternating blunt and sharp dissection using electrocautery, the anterior surface of the breast tissue was taken off of the breast flap. The nipple areolar complex was preserved. However, the terminal ducts were taken and marked. The nipple was not cored out as this was not necessarily helpful to decreasing tumor burden as the tumor was on the medial portion of the breast. However, the terminal ducts were marked separately for pathology.

Once the anterior surface of the breast was freed, the inferior border of the pectoralis muscle was divided and the pectoralis muscle was taken off of its insertion along the medial aspect of the pectoralis muscle. This was done because the previous specimens showed involvement of the desmoid tumor and, therefore, the muscle had to be removed. I took the pectoralis muscle all the way medially to past midline. Deep to the pectoralis muscle most of the capsule was taken as well, leaving the capsule that was adherent to the ribs. Axillary lymph nodes were removed in a prior surgery. All bleeding was controlled carefully with electrocautery, and no significant bleeding was encountered. The specimen was removed and the axillary tail was marked as well as the area that was directly under the previous scar. This was sent to pathology.

At this point, please see Dr. B dictation for completion of this case with insertion of tissue expander. I was present at the closure. The 10 cm incision was then closed in multiple layers. I inserted the On-Q pain pump into the surgical cavity at the top of the cavity and around the area of the dissected remaining pectoralis pedicle. The Jackson-Pratt was placed under the allograft. The allograft had been scored by Dr. B and the drain was sutured in place.

Final Pathological Diagnosis

A. Gross diagnosis: breast implant. Cultures sent from operating room

B. Breast, left: subcutaneous mastectomy; desmoid tumor extra abdominal

  • Residual fibromatosis around site of previous excision
  • Fibrous capsule formation at the deep aspect of specimen, secondary to implant

NOTE: Although scarring secondary to the previous procedures complicates assessment, residual fibromatosis is noted to focally extend to the anterior margin of the mastectomy specimen in the form of fine tendrils. Slides from the previous cases were reviewed in comparison.

Gross Description:

A. The specimen is labeled left breast implant. Received without formalin is a discoid-shaped breast implant measuring 10.5 cm in diameter marked with the following imprint: MENTOR 1234567. Multiple light tan to yellow particles are noted floating in the implant fluid. No sections submitted. The specimen was initially received with a request for culture. It was returned to the operating room before the container was opened so that cultures could be sent under sterile conditions.

B. The specimen is labeled left breast total mastectomy. Received fresh, intraoperatively for inking, is a portion of fibrofatty tissue (subcutaneous mastectomy) measuring 11.5 x 11.5 x 2.5 cm. A long single stitch marks axillary tail, short single stitch marks terminal ducts and long double stitch marks tissue underneath the previous scar (surgical site). The specimen is inked as follows: anterior-red, superior-green, inferior-blue, lateral-orange, medial-yellow, and deep-black. A previous surgical site is noted in the medial aspect of the specimen measuring 2 x 2 x 1.8 cm. The central portion of the deep aspect of the specimen is smooth and shiny; it is the surface that overlay the implant, and is not margin. At the upper or free section of this area, there is fatty/soft tissue that is deep margin. The previous surgical site is predominantly in the area with the described smooth deep aspect. Cut section shows dense white-tan rubbery tissue at the periphery of the previous surgical site and yellow fatty tissue elsewhere. Representative sections are submitted as follows: #1-3 superior margin, #4-6 lateral margin, #7-9 inferior margin, #10-12 medial margin, #13-15 medial margin adjacent to the previous surgical site, #16-17 superior aspect of previous surgical site, #18-19 lateral aspect of the previous surgical site, #20-22 inferior aspect of previous surgical site, #23 terminal duct area, #24-25 deep margin adjacent to previous surgical site, #26-29 deep margin/aspect random sections, #31-34 representative sections of the remaining breast tissue, including anterior margin.

How would this scenario be coded using 2011 codes?

CPT Code and Rationale
19305 -52-LT Mastectomy, radical, including pectoral muscles, axillary lymph nodes

The excision of the pectoralis muscle would be considered part of the mastectomy procedure. Code 19305 best describes the service rendered according to the operative report. However, because the documentation does not indicate that any axillary lymph nodes were removed, it would be appropriate to append modifier 52 Reduced Services to the procedure code. This indicates to the insurance carrier that some of the services included in the code descriptor were not performed. A copy of the operative report should be attached to the claim as well.

Note that while the pathology report describes a subcutaneous mastectomy, which would be identified by CPT code 19304, the operative is clear that the surgeon removed the pectoralis muscle due to the desmoid tumor involvement. As a result, it would necessitate assigning a code for the more radical mastectomy procedure identified by CPT code 19305, even though the lymph nodes were not removed.

ICD-9-CM Code
238.1 Neoplasm of uncertain behavior of connective and other soft tissue

The ICD-9-CM index indicates that an extra-abdominal desmoid tumor should be referenced under the neoplasm table as uncertain behavior of the connective tissue.

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