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Any assistance with this coding would be greatly appreciated. The following case has me stumped for the ICD-9 coding and probably need confirmation of CPT codes as well! Thank you all in advance.
ANESTHESIA: Local with monitored anesthesia care.
ASSISTANT: None.
PREOPERATIVE DIAGNOSIS:
Conjunctival and corneal lesion, right eye suspicious for squamous ocular surface neoplasia.
POSTOPERATIVE DIAGNOSIS:
Conjunctival and corneal lesion, right eye suspicious for squamous ocular surface neoplasia.
OPERATION PERFORMED:
1. Excision of corneal lesion.
2. Excision of conjunctival lesion.
3. Ocular surface reconstruction using amniotic membrane graft.
4. Cryotherapy.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.
SPECIMENS: Keratoconjunctival lesion to pathology.
INDICATIONS FOR PROCEDURE: The patient is a pleasant 62-year-old gentleman who has noticed a bump on his right eye for several months. He also complains of some irritation and soreness. The patient and his wife note that the bump has been increasing in size as of late. Examination reveals a large keratoconjunctival mass. This does not have the appearance of the pterygium. Rather the area has a ground glass-type appearance with fronds growing onto the cornea. The patient does have history of two previous primary cancers including renal cell carcinoma which was metastatic to the bones, lungs and brain as well as previous prostate cancer. After full description of the risks, benefits and alternatives to the proposed procedure with the risks including pain, bleeding, infection and loss of vision, loss of the eye, need for more surgery, possible spread of tumor cells, slow healing due to chemotherapy, need for further chemotherapy as well as others the decision was made to proceed with excision of the keratoconjunctival lesion with ocular surface reconstruction using amniotic membrane graft as well as cryotherapy.
DESCRIPTION OF PROCEDURE: The patient was brought to the preoperative holding area to the operating suite where he was identified by the surgeon. The patient’s right eye was prepped and draped in the standard, sterile fashion except no iodine-containing products were used. Preoperatively TetraVisc was used to numb the eye and one drop of phenylephrine was used for dilation. The area of the growth had been delineated with the slit lamp preoperatively to make a preoperative sketch. The lid speculum was placed and the operating microscope was swung into position. The eye was examined and there was found to be a large, approximately 11 mm, temporal corneal limbal mass with ground-glass appearance as well as fronding pattern. A large conjunctival lesion was also noted which extended approximately 9 mm from the limbus. The conjunctival lesion did not appear as suspicious for neoplasia as the corneal lesion though they were attached.
Traction suture was placed to the nasal limbus using 8-0 Vicryl. A corneal light shield was placed and used throughout the case to prevent phototoxicity. The subconjunctival mass was marked using a fine tip marker leaving a margin of approximately 3-4 mm. 1% lidocaine with epinephrine was used to raise the conjunctival mass. The conjunctival portion of the tumor was excised with Westcott scissors. The conjunctival portion of the tumor was not adherent to the sclera. Pressure was applied to the scissors when removing the limbal portion of the tumor so that they were flush with the sclera and were able to cut underneath the tumor. A Weck-Cel spear soaked in dehydrated alcohol was applied to the corneal surface at the temporal limbus for 60 seconds. The alcohol was then washed away with copious balanced salt solution. A Beaver blade was used to scroll the corneal epithelium to the limbus including the limbal mass and the corneal portion of this mass.
The corneal and conjunctival portions of the mass were removed en bloc and placed on a pencil and drawn diagram on paper. This was allowed to dry and then placed in the formalin solution. Nasal temporal superior and inferior as well as limbal areas were marked. The limbus and scleral bed were then scraped with a blade. No residual areas of mass were noted on the cornea were conjunctiva. No breach of Bowman membrane was noted. Cryotherapy was then applied to the limbus and conjunctival margins using a double freeze-thaw, slow-thaw cycle. The eye was again rinsed using BSS. The previous instruments were removed and fresh instruments were used in closure of the conjunctival defect. The cornea and conjunctival portions of the tumor were removed using a "no touch" technique. The eye was examined and there was found to be a 12 x 14 mm area of conjunctival defect. This was thought to be too large for primary closure so the decision was made to use amniotic membrane graft. Amniograft brand amniotic membrane was thawed and removed from the backing paper and placed on the articular surface with the stromal sticky side facing down. It was trimmed prior to being removed from the paper to fit the conjunctival defect. Tisseel brand tissue glue was used to affix the amniotic membrane graft to the bare sclera. Two smooth ties as well as a muscle hook were used to ensure proper coverage of the scleral defect with amniotic membrane. Electrocardiogram of the amniotic membrane was then tested using Weck-Cel sponges and was found to be well-adhered to the underlying sclera. Excess membrane include were trimmed off the ocular surface. The traction suture was then removed. Drops of Vigamox and TobraDex ointment were instilled after removal of the lid speculum. A patch and shield were placed and the patient was sent to recovery in stable condition.
DISCHARGE ORDERS: Condition stable. Activity light with no bending, lifting, or eye rubbing. The patient is to keep the eye patch and shield at all times.
DISCHARGE MEDICATIONS: Tylenol one to two p.o. every four to six hours p.r.n. pain.
FOLLOW-UP INSTRUCTIONS: The patient is to follow-up in the office tomorrow at 8 o’clock a.m.
The patient is to call as soon as possible if there is significant pain, headache or any other problems.
* The path report states: "SQUAMOUS METAPLASIA AND MILD DYSPLASIA, ARISING IN PTERYGIUM"
ANESTHESIA: Local with monitored anesthesia care.
ASSISTANT: None.
PREOPERATIVE DIAGNOSIS:
Conjunctival and corneal lesion, right eye suspicious for squamous ocular surface neoplasia.
POSTOPERATIVE DIAGNOSIS:
Conjunctival and corneal lesion, right eye suspicious for squamous ocular surface neoplasia.
OPERATION PERFORMED:
1. Excision of corneal lesion.
2. Excision of conjunctival lesion.
3. Ocular surface reconstruction using amniotic membrane graft.
4. Cryotherapy.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.
SPECIMENS: Keratoconjunctival lesion to pathology.
INDICATIONS FOR PROCEDURE: The patient is a pleasant 62-year-old gentleman who has noticed a bump on his right eye for several months. He also complains of some irritation and soreness. The patient and his wife note that the bump has been increasing in size as of late. Examination reveals a large keratoconjunctival mass. This does not have the appearance of the pterygium. Rather the area has a ground glass-type appearance with fronds growing onto the cornea. The patient does have history of two previous primary cancers including renal cell carcinoma which was metastatic to the bones, lungs and brain as well as previous prostate cancer. After full description of the risks, benefits and alternatives to the proposed procedure with the risks including pain, bleeding, infection and loss of vision, loss of the eye, need for more surgery, possible spread of tumor cells, slow healing due to chemotherapy, need for further chemotherapy as well as others the decision was made to proceed with excision of the keratoconjunctival lesion with ocular surface reconstruction using amniotic membrane graft as well as cryotherapy.
DESCRIPTION OF PROCEDURE: The patient was brought to the preoperative holding area to the operating suite where he was identified by the surgeon. The patient’s right eye was prepped and draped in the standard, sterile fashion except no iodine-containing products were used. Preoperatively TetraVisc was used to numb the eye and one drop of phenylephrine was used for dilation. The area of the growth had been delineated with the slit lamp preoperatively to make a preoperative sketch. The lid speculum was placed and the operating microscope was swung into position. The eye was examined and there was found to be a large, approximately 11 mm, temporal corneal limbal mass with ground-glass appearance as well as fronding pattern. A large conjunctival lesion was also noted which extended approximately 9 mm from the limbus. The conjunctival lesion did not appear as suspicious for neoplasia as the corneal lesion though they were attached.
Traction suture was placed to the nasal limbus using 8-0 Vicryl. A corneal light shield was placed and used throughout the case to prevent phototoxicity. The subconjunctival mass was marked using a fine tip marker leaving a margin of approximately 3-4 mm. 1% lidocaine with epinephrine was used to raise the conjunctival mass. The conjunctival portion of the tumor was excised with Westcott scissors. The conjunctival portion of the tumor was not adherent to the sclera. Pressure was applied to the scissors when removing the limbal portion of the tumor so that they were flush with the sclera and were able to cut underneath the tumor. A Weck-Cel spear soaked in dehydrated alcohol was applied to the corneal surface at the temporal limbus for 60 seconds. The alcohol was then washed away with copious balanced salt solution. A Beaver blade was used to scroll the corneal epithelium to the limbus including the limbal mass and the corneal portion of this mass.
The corneal and conjunctival portions of the mass were removed en bloc and placed on a pencil and drawn diagram on paper. This was allowed to dry and then placed in the formalin solution. Nasal temporal superior and inferior as well as limbal areas were marked. The limbus and scleral bed were then scraped with a blade. No residual areas of mass were noted on the cornea were conjunctiva. No breach of Bowman membrane was noted. Cryotherapy was then applied to the limbus and conjunctival margins using a double freeze-thaw, slow-thaw cycle. The eye was again rinsed using BSS. The previous instruments were removed and fresh instruments were used in closure of the conjunctival defect. The cornea and conjunctival portions of the tumor were removed using a "no touch" technique. The eye was examined and there was found to be a 12 x 14 mm area of conjunctival defect. This was thought to be too large for primary closure so the decision was made to use amniotic membrane graft. Amniograft brand amniotic membrane was thawed and removed from the backing paper and placed on the articular surface with the stromal sticky side facing down. It was trimmed prior to being removed from the paper to fit the conjunctival defect. Tisseel brand tissue glue was used to affix the amniotic membrane graft to the bare sclera. Two smooth ties as well as a muscle hook were used to ensure proper coverage of the scleral defect with amniotic membrane. Electrocardiogram of the amniotic membrane was then tested using Weck-Cel sponges and was found to be well-adhered to the underlying sclera. Excess membrane include were trimmed off the ocular surface. The traction suture was then removed. Drops of Vigamox and TobraDex ointment were instilled after removal of the lid speculum. A patch and shield were placed and the patient was sent to recovery in stable condition.
DISCHARGE ORDERS: Condition stable. Activity light with no bending, lifting, or eye rubbing. The patient is to keep the eye patch and shield at all times.
DISCHARGE MEDICATIONS: Tylenol one to two p.o. every four to six hours p.r.n. pain.
FOLLOW-UP INSTRUCTIONS: The patient is to follow-up in the office tomorrow at 8 o’clock a.m.
The patient is to call as soon as possible if there is significant pain, headache or any other problems.
* The path report states: "SQUAMOUS METAPLASIA AND MILD DYSPLASIA, ARISING IN PTERYGIUM"
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