tdesher
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Can someone help me decipher which to code please?
PREOPERATIVE DIAGNOSES: Bilateral lower eyelid ectropion with horizontal lid laxity.
POSTOPERATIVE DIAGNOSES: Bilateral lower eyelid ectropion with horizontal lid laxity.
PROCEDURES PERFORMED: Bilateral lower eyelid conjunctivoplasty with horizontal lid tightening.
ANESTHESIA: MAC.
The lower eyelids and lateral canthal areas were infiltrated using 2% lidocaine with 1:100,000 epinephrine and hyaluronidase. The patient was prepped and draped in usual sterile manner.
The left lower eyelid was everted, and a needle-tipped cautery was used to excise the diamond-shaped segment of conjunctiva and lower eyelid retractors extending from proximal 3 mm inferior to the punctum to 3 mm superior to the cul-de-sac. A double-armed 5-0 chromic suture was used to take a bite of the orbicularis muscle centrally. One arm of the suture was passed through superotemporal and one through the superomedial limbs of the excision.
Each arm was passed to the corresponding lower limb of the excision, and drawn out anteriorly out through the skin, the knot was tied resulting in full correction of the medial aspect of the ectropion.
An identical procedure was performed on the opposite side.
Westcott scissors were used to perform a lateral canthotomy on the left lower eyelid. The eyelid was drawn temporarily, the amount of excess determined and excised. Two 4-0 Vicryl sutures were used to reapproximate the tarsus to the periorbit inside the orbital rim, taking care to ensure appropriate height, contour, and symmetry. The anterior lamella was closed using 6-0 fast-absorbing gut suture.
An identical procedure was performed on the opposite side.
PREOPERATIVE DIAGNOSES: Bilateral lower eyelid ectropion with horizontal lid laxity.
POSTOPERATIVE DIAGNOSES: Bilateral lower eyelid ectropion with horizontal lid laxity.
PROCEDURES PERFORMED: Bilateral lower eyelid conjunctivoplasty with horizontal lid tightening.
ANESTHESIA: MAC.
The lower eyelids and lateral canthal areas were infiltrated using 2% lidocaine with 1:100,000 epinephrine and hyaluronidase. The patient was prepped and draped in usual sterile manner.
The left lower eyelid was everted, and a needle-tipped cautery was used to excise the diamond-shaped segment of conjunctiva and lower eyelid retractors extending from proximal 3 mm inferior to the punctum to 3 mm superior to the cul-de-sac. A double-armed 5-0 chromic suture was used to take a bite of the orbicularis muscle centrally. One arm of the suture was passed through superotemporal and one through the superomedial limbs of the excision.
Each arm was passed to the corresponding lower limb of the excision, and drawn out anteriorly out through the skin, the knot was tied resulting in full correction of the medial aspect of the ectropion.
An identical procedure was performed on the opposite side.
Westcott scissors were used to perform a lateral canthotomy on the left lower eyelid. The eyelid was drawn temporarily, the amount of excess determined and excised. Two 4-0 Vicryl sutures were used to reapproximate the tarsus to the periorbit inside the orbital rim, taking care to ensure appropriate height, contour, and symmetry. The anterior lamella was closed using 6-0 fast-absorbing gut suture.
An identical procedure was performed on the opposite side.