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Jamie Dezenzo

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POSTOPERATIVE DIAGNOSIS: Suspicious lesion with excessive mucous production and bleeding in the right eye socket and inability to wear the prosthesis.

PROCEDURES PERFORMED: Tarsorrhaphy lateral right eye, excision of 2 cm lesion from the right socket.


Attention was directed to the lesion in the right socket. The stalk was severed. Hemostasis was obtained with a Bovie electrocautery. The lesion was sent for pathologic analysis (PATH BN POLYPOID GRANULATION TISSUE)

Attention was directed to the tarsorrhaphy. The lid was divided into anterior and posterior lamella. The tarsal plate was transposed and sutured together with 4-0 Vicryl sutures. Meticulous hemostasis was obtained.

looking at 67882 for tarsorrhaphy but not sure about socket mass??? Thoughts

Thanks
Jamie
 
Since your note states that the patient is unable to wear the prosthesis, I'm assuming the eye has been removed. Polypoid just means polyp like, I would concentrate on lesion and/or granulation tissue. If it's a lesion of the bony socket, ICD9 under Lesion directs you to 733.90 Disorder of bone and cartilage. Using the path report, in the alpha section of ICD9 post op granuation tissue directs you to 701.5.

AHA Coding Clinic First Quarter 2006 regarding Mass, Lump or Lesion states that if there is no specific index entry for the affected organ or site under "mass", "lump" or "lesion", then look for the organ or site under "Disease, diseased".

The eye orbit can refer to the contents of the orbit or the bony socket. Under Disease in the Alpha section, orbit refers you to 376.9 Unspecified disorder of orbit or maybe 376.89 Other orbital disorders.
 
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You may be looking at an unlisted code for the exicsion of the polypoid lesion, 67599 Unlisted procedure, orbit. On the other hand, is the tarsorrhaphy being done to protect the eye after excision of the lesion? In that case, the excision might be included in the tarsorrhaphy.
 
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