sirisha
Contributor
Hi,
I am new to this specialty. It will be very much grateful if anyone help me in deriving with the correct CPT codes for the below operative report.
POSTOPERATIVE DIAGNOSIS: Nose basal cell skin cancer.
PROCEDURE PERFORMED:
1.Bilateral nasolabial flap division.
2.Bilateral nasolabial flap revision, 4 x 3 cm, which equals 12 cm2.
ASSISTANT: None.
ANESTHESIA: General.
TOURNIQUET TIME: None.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS/HARDWARE: None.
COMPLICATIONS: None.
FINDINGS: The patient had a cartilage excision on the left.
SPECIMEN TO PATHOLOGY: None.
DISPOSITION: To PACU.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed onto the operating table in the supine position. After general anesthesia was induced, the patient was intubated without any complication. Once the ET tube was fixed in place, the patient was then prepped and draped in the usual sterile fashion. At this time, I then began with the procedure. Starting with the right side, I began to divide the flap at the base of the flap. This was then divided using a #15 blade. The donor site was then contoured and made level, and this was then sutured in place using a 4-0 Vicryl followed by a 5-0 nylon suture. Once the flap was divided, I was able to began to revise the right side of the flap onto the defect. This was then contoured and fixed in place using a 4-0 Vicryl followed by a 5-0 nylon suture in an interrupted fashion. Once this was completed, I then focused my attention on the contralateral left side. At this time, the flap was then divided at the donor base. Because there is a greater defect on the nasal ala, I was able to further divide this flap partially to help rotate this onto that defect, which I was able to perform successfully. The intranasal excess cartilage was then excised. This was then sutured in place to approximate the edges. Once this was fixed in place, the total bilateral nasal flap revision was 4 x 3 cm, which equals 12 cm2. The patient postoperatively appears to have a good, viable flap rotation. A sterile dressing was then placed. The patient tolerated the entire procedure without any complication. The patient was then weaned off general anesthesia and extubated.
Thank a lot in advance.
Sirisha
I am new to this specialty. It will be very much grateful if anyone help me in deriving with the correct CPT codes for the below operative report.
POSTOPERATIVE DIAGNOSIS: Nose basal cell skin cancer.
PROCEDURE PERFORMED:
1.Bilateral nasolabial flap division.
2.Bilateral nasolabial flap revision, 4 x 3 cm, which equals 12 cm2.
ASSISTANT: None.
ANESTHESIA: General.
TOURNIQUET TIME: None.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS/HARDWARE: None.
COMPLICATIONS: None.
FINDINGS: The patient had a cartilage excision on the left.
SPECIMEN TO PATHOLOGY: None.
DISPOSITION: To PACU.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed onto the operating table in the supine position. After general anesthesia was induced, the patient was intubated without any complication. Once the ET tube was fixed in place, the patient was then prepped and draped in the usual sterile fashion. At this time, I then began with the procedure. Starting with the right side, I began to divide the flap at the base of the flap. This was then divided using a #15 blade. The donor site was then contoured and made level, and this was then sutured in place using a 4-0 Vicryl followed by a 5-0 nylon suture. Once the flap was divided, I was able to began to revise the right side of the flap onto the defect. This was then contoured and fixed in place using a 4-0 Vicryl followed by a 5-0 nylon suture in an interrupted fashion. Once this was completed, I then focused my attention on the contralateral left side. At this time, the flap was then divided at the donor base. Because there is a greater defect on the nasal ala, I was able to further divide this flap partially to help rotate this onto that defect, which I was able to perform successfully. The intranasal excess cartilage was then excised. This was then sutured in place to approximate the edges. Once this was fixed in place, the total bilateral nasal flap revision was 4 x 3 cm, which equals 12 cm2. The patient postoperatively appears to have a good, viable flap rotation. A sterile dressing was then placed. The patient tolerated the entire procedure without any complication. The patient was then weaned off general anesthesia and extubated.
Thank a lot in advance.
Sirisha