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How do you code this procedure?
CHART NOTE #8
DATE OF OPERATION: May 22, 20xx
PREOPERATIVE DIAGNOSIS: Ptosis left upper lid and hooding both upper lids.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Left upper lid Mueller muscle resection,
Advancement 10.0 mm and bilateral funcational
Upper lid blepharoplasties.
ANESTHESIA: Local plus IV sedation.
INDICATIONS FOR PROCEDURE: The patient is a pleasant male with blepharoptosis of the left upper lid and hooding of both upper lids independently causing superior visual field obscuration, which in turn causes difficulties with activities of daily living.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed on the operating table in the supine position. After adequate IV anesthesia was obtained, the patient's face was prepped and draped in the usual sterile fashion. 2% Xylocaine with epinephrine and equal parts 0.75% Marcaine was injected in both upper lids after the lid creases had been delineated and the amount of skin to be excised determined by the pinch technique. Attention was first directed to the left upper lid, which was inverted over Desmarres retractor and 2% Xylocaine without epinephrine was injected subconjunctivally. Four interrupted 6-0 Vicryl sutures were place 5 mm above the superior tarsal border through conjunctiva and Mueller muscle and the sutures were used to tent the tissue superiorly as the Mueller muscle clamp was placed across the tissue and the double arm 6-0 gut suture was woven at the base of the clamp. The clamp and its contents were amputated using a 15 blade and the medial arm of the suture was then used to oversew the wound. Both arms of the suture were brought out through the skin laterally where they were tied securely. Attention was then directed to the right upper lid where a CO2 laser was set at 4 watts, 20 mJ, 200 pulses/sec. This laser was used to incise along the previously delineated skin lines and the skin muscle flap was excised the discarded. The orbital septum was entered and the orbital fat was prolapsed, cut and cauterized and the wound was then closed using interrupted 6-0 mild chromic and a running 7-0 Prolene. Attention was directed to the contralateral upper lid where an identical procedure was performed. Metal contact lenses were removed from that eye. The patient tolerated the procedure well and left the operating room in good condition. No complications or specimens to the case.
CHART NOTE #8
DATE OF OPERATION: May 22, 20xx
PREOPERATIVE DIAGNOSIS: Ptosis left upper lid and hooding both upper lids.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Left upper lid Mueller muscle resection,
Advancement 10.0 mm and bilateral funcational
Upper lid blepharoplasties.
ANESTHESIA: Local plus IV sedation.
INDICATIONS FOR PROCEDURE: The patient is a pleasant male with blepharoptosis of the left upper lid and hooding of both upper lids independently causing superior visual field obscuration, which in turn causes difficulties with activities of daily living.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed on the operating table in the supine position. After adequate IV anesthesia was obtained, the patient's face was prepped and draped in the usual sterile fashion. 2% Xylocaine with epinephrine and equal parts 0.75% Marcaine was injected in both upper lids after the lid creases had been delineated and the amount of skin to be excised determined by the pinch technique. Attention was first directed to the left upper lid, which was inverted over Desmarres retractor and 2% Xylocaine without epinephrine was injected subconjunctivally. Four interrupted 6-0 Vicryl sutures were place 5 mm above the superior tarsal border through conjunctiva and Mueller muscle and the sutures were used to tent the tissue superiorly as the Mueller muscle clamp was placed across the tissue and the double arm 6-0 gut suture was woven at the base of the clamp. The clamp and its contents were amputated using a 15 blade and the medial arm of the suture was then used to oversew the wound. Both arms of the suture were brought out through the skin laterally where they were tied securely. Attention was then directed to the right upper lid where a CO2 laser was set at 4 watts, 20 mJ, 200 pulses/sec. This laser was used to incise along the previously delineated skin lines and the skin muscle flap was excised the discarded. The orbital septum was entered and the orbital fat was prolapsed, cut and cauterized and the wound was then closed using interrupted 6-0 mild chromic and a running 7-0 Prolene. Attention was directed to the contralateral upper lid where an identical procedure was performed. Metal contact lenses were removed from that eye. The patient tolerated the procedure well and left the operating room in good condition. No complications or specimens to the case.