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Find the correct ICD-10 (diagnosis) and CPT (procedure) codes for this case PREOPERATIVE DIAGNOSES: Fat atrophy of the latissimus dorsi flap of right breast. Asymmetry of the breasts. Scar tissue, right side of back incision. POSTOPERATIVE DIAGNOSES: Same. INDICATIONS: 56-year-old who is now 4 months post mastectomy of the right breast. SURGICAL FINDINGS: 1. There was a clean and relatively avascular pectoralis submuscular pocket on the right side. 2. There was what appeared to be scar tissue mass with fat necrosis, also a cutaneous scar, of the more lateral aspect of the donor site from the previous latissimus dorsi flap. SURGICAL PROCEDURES: Insertion of submuscular breast implant, right breast. 150 cc implant was used. Excision of scar tissue, donor area on latissimus dorsi flap, right side of back. DESCRIPTION OF PROCEDURE: The patient’s chest and right side of the back were prepped with Betadine scrub and solution and draped in a routine sterile fashion. I injected a total of about 5 cc of 1% Xylocaine, 1 : 100,000 epinephrine in both the incision site of the medial aspect of the right breast and the back incision. The scar was excised from the lower aspect of the right breast, and a right pectoralis submuscular pocket was created using the balloon dissector to aid in dissection. Hemostasis was satisfactory, and following insertion of the balloon dissector, which we inflated to about 300 cc, I inserted a 230 cc Pfizer. This obviously was too large compared to the left side. In accordance with the patient’s wishes, we put a 150 cc implant in, which made the right breast appear to be somewhat larger than the left, although they appeared the same with the patient in the recumbent position. The patient had expressly told us that she wished to have the right breast to be somewhat larger than the left breast and we tried to comply with the patient’s wishes by insertion of the 150 cc implant. I felt that 100 cc would perhaps be too small, but the 150 cc did make the right breast larger than the left, although this may equilibrate more with the patient in the standing position. After insertion of the implant, I closed the wound with fascial sutures of 3-0 Monocryl and used interrupted twists of 5-0 Prolene. I excised the scar on the back in continuity with some scar tissue underneath and then excised a separate nodule of apparent scar tissue and fat necrosis, closing 6.8-cm wound with subcuticular 3-0 Monocryl in interrupted twists using some horizontal mattress twists of 4-0 Prolene. Xeroform and a 4 x 4 were applied to the back, and Kerlix fluffs and a support bra were used to dress the right breast reconstruction. Estimated blood loss was negligible. No drains were inserted. The patient tolerated the procedure well and left the operating room in good condition. Procedure Key Terms: breast prosthesis, delayed insertion ICD-IO-CM Key Terms: atrophy of breast, scar tissue skin #2

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