Wiki Open reduction of rt orbital rim/roof fx with internal fixation

bgbarrett

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Any advice on coding this. I have 21406 or 21366... Not sure if all can be captured in 1 code?

1. Open reduction and internal fixation of right superior orbital rim fracture.
2. Open reduction of right orbital roof fracture with fixation with Resorb-x plate.
3. Reduction fixation of cranial frontal bone fracture with resorbable PDS suture.

Prior to beginning the incisions, I performed a forced duction of the right globe, and patient had full range of motion of the eye in all directions. There was no entrapment. I freed the periorbita anteriorly the superior portion of the globe in the orbit from superior orbital rim and helped to free up this bony fragment. It was perpendicular to the orbital roof. This was removed temporarily. I fashioned a Resorb-x plate to be covered at the posteromedial aspect of the orbital roof and held it in place with 2 SonicWeld screws medially and laterally with good fixation to cover the orbita and the defect over the ethmoid communication. The superior orbital rim fracture was fixated with drill holes and 3-0 PDS suture. The patient also had a fracture at the right frontal zygomatic junction of the right lateral orbit, slightly displaced. It was secured with fixation with PDS suture as well. The Pericranial flap was brought down to cover the defect over the reduced fracture. Then, once Dr. X had secured excellent hemostasis, the bone flap was replaced and held securely with 0 PDS suture. A drain was placed, brought through a stab wound in the left parietal area, held in place with 3-0 Prolene suture; and then the wound scalp was closed after assuring excellent hemostasis. The scalp was closed with buried 4-0 Monocryl galeal subdermal sutures followed by a running 4-0 Monocryl suture topped with Bactroban ointment.

This was done in conjunction with a neurosurgeon performing the craniotomy & dural tear repair.
 
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