DX: Left loer lid ectropian and left lower eyelid scarring
Description of proc: Following the administration of local anesthesia the pt was prepped and draped in the usual sterile ophthamic fashion. The area of scar on the left cheek and left loer eyelid were excised. Hemostasis was obtained. The scarring had shortened the tissue on the face and lower orbital rim and had caused ectropian. The tissue was dissected down to the orbital rim in order to free up the preseptal tissue. the preseptal tissue was secured to the lateral orbital rim at a higher position using 5-0 nylon interrupted suture. The remaining scar tissue was excised. A section of tarsus was laterally was removed and a tarsel strip was made laterally. The tarsus was anchored to the lateral orbital rim using 2 interrupted 5-0 sutures. The redundant fat that was prolapsed was cauterized. The skin was stretched and sutured using a combination of interrupted and horizontal mattress sutures.Kenalog was injected throughout the wound margin. Maxitrol ointment was instilled. A pressure patch was applied.
How would you code this , I'm stumped. Needing to get this coded as we are end of month
Thanks
Paula
Description of proc: Following the administration of local anesthesia the pt was prepped and draped in the usual sterile ophthamic fashion. The area of scar on the left cheek and left loer eyelid were excised. Hemostasis was obtained. The scarring had shortened the tissue on the face and lower orbital rim and had caused ectropian. The tissue was dissected down to the orbital rim in order to free up the preseptal tissue. the preseptal tissue was secured to the lateral orbital rim at a higher position using 5-0 nylon interrupted suture. The remaining scar tissue was excised. A section of tarsus was laterally was removed and a tarsel strip was made laterally. The tarsus was anchored to the lateral orbital rim using 2 interrupted 5-0 sutures. The redundant fat that was prolapsed was cauterized. The skin was stretched and sutured using a combination of interrupted and horizontal mattress sutures.Kenalog was injected throughout the wound margin. Maxitrol ointment was instilled. A pressure patch was applied.
How would you code this , I'm stumped. Needing to get this coded as we are end of month
Thanks
Paula