codedog
True Blue
ANY ideas how to code this procedure?
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma of the right medial canthal area, status post excision, status post cross-lid flap for lid reconstruction.
OPERATION: Release of cross-lid flap and inset of the base and also inset of the distal flap on the lower lid.
HISTORY: The patient approximately a month ago had a resection of a medial canthal tumor involving skin of the upper lid and medial canthus. She was reconstructed with a cheek advancement flap, for which nothing further needed be done and the lid itself was resurfaced with a flap from the upper lid which crossed between the lids and required releasing.
PROCEDURE:
She was taken to the operating room and placed under adequate basal sedation. A small amount of local was injected in the upper lid. A hemostat was placed in the bridge of the flap where the flap bridged the two lids and the flap was incised. The proximal flap was then unfurled along its scar margin. The underlying orbicularis muscle was excised. The flap was then trimmed to fit the underlying defect and repaired with 6-0 chromic sutures. The distal flap was then also unfurled in its upper third. The underlying orbicularis was removed to flatten the flap. Two triangles of skin were removed in order to allow the flap to then lie flat on the lid and the flap was repaired with multiple 6-0 chromic sutures. Antibiotic ointment completed the closure. The patient tolerated the procedure well and was sent back to the recovery room in good condition.
this one I am not sure,any suggestions , If I had to guess it would be 15630?would it just be one code ?
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma of the right medial canthal area, status post excision, status post cross-lid flap for lid reconstruction.
OPERATION: Release of cross-lid flap and inset of the base and also inset of the distal flap on the lower lid.
HISTORY: The patient approximately a month ago had a resection of a medial canthal tumor involving skin of the upper lid and medial canthus. She was reconstructed with a cheek advancement flap, for which nothing further needed be done and the lid itself was resurfaced with a flap from the upper lid which crossed between the lids and required releasing.
PROCEDURE:
She was taken to the operating room and placed under adequate basal sedation. A small amount of local was injected in the upper lid. A hemostat was placed in the bridge of the flap where the flap bridged the two lids and the flap was incised. The proximal flap was then unfurled along its scar margin. The underlying orbicularis muscle was excised. The flap was then trimmed to fit the underlying defect and repaired with 6-0 chromic sutures. The distal flap was then also unfurled in its upper third. The underlying orbicularis was removed to flatten the flap. Two triangles of skin were removed in order to allow the flap to then lie flat on the lid and the flap was repaired with multiple 6-0 chromic sutures. Antibiotic ointment completed the closure. The patient tolerated the procedure well and was sent back to the recovery room in good condition.
this one I am not sure,any suggestions , If I had to guess it would be 15630?would it just be one code ?