Procedure: Modified radical mastectomy Diagnosis: Left lower outer quadrant breast carcinoma with metastases to the axillary lymph nodes Anesthesia: General Technique: This 58-year-old female patient was placed under general anesthesia, after which the patient’s left breast was prepped and draped. A transverse elliptical incision was made, including the nipple, areolar complex and the previous biopsy site. Skin flaps were elevated medially to the sternum, superiorly to the clavicle, laterally to the latissimus, and inferiorly to the rectus. The fascia was dissected medial to lateral with cautery dissection. The axilla was entered and the axillary vein identified. The venous tributaries were clipped inferiorly and divided. The long thoracic c and thoracodorsal nerves were identified and traced to their insertions. The axillary lymph chain contents were taken out with the breast specimen. Hemostasis was obtained. Two Jackson Pratt drains were placed. The subcutaneous tissue was re-approximated with interrupted 3-0 Vicryl, and the skin was closed with clips. The skin flaps were trimmed prior to closure for a more cosmetically acceptable. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition. You are coding for the surgeon only. CPT Code(s): ICD-10-CM Code(s):
[Answered]: Procedure: Modified radical mastectomy Diagnosis:…
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