mducharme82
New
Having a disagreement need second opinon!
Could you let me know how you would code this? I feel its one way but I'm new to coding eyes Please Help
POSTOPERATIVE DIAGNOSES:
1. Basal cell carcinoma with operative defect after Moh?s excision right medial canthus.
2. Epiphora right side.
PROCEDURES:
1. Repair and reconstruction of right medial canthus involving probing and irrigation of right lacrimal outflow system.
2. Right adjacent tissue rearrangement
DESCRIPTION OF PROCEDURE: Informed consent was obtained and the patient?s right side was marked in the preoperative holding area. Under IV sedation 2 cc of local anesthetic was injected into the site. They were then sterilely prepped and draped for surgery.
A punctal dilator was used to dilate the upper and lower puncta. Irrigation was performed and found to be free to the nose. Exploration with the Bowman probe showed the understands canalicular lacrimal system to be intact without trauma from the excision of the cancer.
Next, the Westcott forceps were used to extensively undermine the skin and muscle around the defect which measured approximately 16 x 19 mm. The 15 blade was then used to create two skin incisions to create an otoZplasty for closure with the tension created in the horizontal vector to avoid undue ectropion of the left upper lid. The 15 blade was used to create two triangular skin muscle flaps for rearrangement.
The adjacent tissue was rearranged. The obicularis muscle was closed using buried interrupted 5-0 Vicryl suture. The skin for the otoZplasty was closed using 6-0 plain gut. The patient tolerated the procedure well. Postoperatively a pressure dressing was fashioned. She was transferred to the PACU and after an uneventful course she was discharged to home to follow up in one week
Could you let me know how you would code this? I feel its one way but I'm new to coding eyes Please Help
POSTOPERATIVE DIAGNOSES:
1. Basal cell carcinoma with operative defect after Moh?s excision right medial canthus.
2. Epiphora right side.
PROCEDURES:
1. Repair and reconstruction of right medial canthus involving probing and irrigation of right lacrimal outflow system.
2. Right adjacent tissue rearrangement
DESCRIPTION OF PROCEDURE: Informed consent was obtained and the patient?s right side was marked in the preoperative holding area. Under IV sedation 2 cc of local anesthetic was injected into the site. They were then sterilely prepped and draped for surgery.
A punctal dilator was used to dilate the upper and lower puncta. Irrigation was performed and found to be free to the nose. Exploration with the Bowman probe showed the understands canalicular lacrimal system to be intact without trauma from the excision of the cancer.
Next, the Westcott forceps were used to extensively undermine the skin and muscle around the defect which measured approximately 16 x 19 mm. The 15 blade was then used to create two skin incisions to create an otoZplasty for closure with the tension created in the horizontal vector to avoid undue ectropion of the left upper lid. The 15 blade was used to create two triangular skin muscle flaps for rearrangement.
The adjacent tissue was rearranged. The obicularis muscle was closed using buried interrupted 5-0 Vicryl suture. The skin for the otoZplasty was closed using 6-0 plain gut. The patient tolerated the procedure well. Postoperatively a pressure dressing was fashioned. She was transferred to the PACU and after an uneventful course she was discharged to home to follow up in one week
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