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what codes would you use for this case?
M000635288 AH0003040498 JOB: 2303376
DATE OF OPERATION: 03/27/2013
PREOPERATIVE DIAGNOSIS: Secondary glaucoma, posterior synechiae, iris bombe, angle closure, previous full-thickness macular hole, intraocular gas tamponade, right eye.
POSTOPERATIVE DIAGNOSIS: Secondary glaucoma, posterior synechiae, iris bombe, angle closure, previous full-thickness macular hole, intraocular gas tamponade, right eye.
NAME OF PROCEDURE: A 25-gauge pars plana vitrectomy, removal of intraocular gas, re-formation of anterior chamber, synechialysis, and surgical peripheral iridectomy, all in the right eye.
SURGEON: xxxxxxxxx MD
ANESTHESIA: Monitored anesthesia care with a retrobulbar block.
ESTIMATED BLOOD LOSS: Less than 1 mL.
COMPLICATIONS: None.
PROCEDURE: The right eye of Mr. xxxxxx was prepped and draped in a sterile fashion, after which a standard 3-port 25-gauge pars plana vitrectomy setup was placed. A back-flush needle was used to remove C3F8 from the eye, and the infusion was clamped. Three paracentesis ports were created at 1 o'clock, 8 o'clock, and 10 o'clock, through which viscoelastic (Provisc) was used to re-form the anterior chamber and to lyse 360 degree posterior synechiae adhering the iris to the posterior chamber lens. The infusion was then opened, and the vitrectomy cutter was used to create an inferior peripheral iridectomy at 5:30. Once the iridectomy was confirmed to be patent, attention was turned posteriorly. A 360-degree examination revealed a fully attached retina. A macular lens was placed on the eye, and examination of the macular showed the full-thickness macular hole to be closed. Any residual debris was removed from the eye using the vitrectomy cutter. The infusion was then again clamped, and balanced saline solution was used to irrigate free any residual viscoelastic in the anterior chamber. The peripheral iridectomy was seen to be patent, and the iris was mobile. One final examination was performed of the posterior segment, which was seen to be free of blood and debris with a flat macula.
The vitrectomy cannulae were then removed, and the sclerotomies were sutured with interrupted 6-0 Vicryl stitches. The anterior chamber was re-pressurized with balanced saline solution, and the paracentesis ports were hydrated. The eye was seen to be well pressurized but soft. The lid speculum and drapes were removed, and the eye was patched and shielded with Cyclogyl drops and TobraDex ointment. The patient returned to the postoperative area in stable condition.
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PRELIMINARY REPORT UNTIL ELECTRONICALLY SIGNED BY PHYSICIAN
DICTATING PHYSICAN: xxxxxxxxx MD
ESIGNING PHYSICIAN:
ESIGN DATE AND TIME:
CC:
Pomerleau,Dustin L MD
DD: 03/27/13 1823 TI: SYN
DT: 03/28/13 0739 LC: 48
M000635288 AH0003040498 JOB: 2303376
DATE OF OPERATION: 03/27/2013
PREOPERATIVE DIAGNOSIS: Secondary glaucoma, posterior synechiae, iris bombe, angle closure, previous full-thickness macular hole, intraocular gas tamponade, right eye.
POSTOPERATIVE DIAGNOSIS: Secondary glaucoma, posterior synechiae, iris bombe, angle closure, previous full-thickness macular hole, intraocular gas tamponade, right eye.
NAME OF PROCEDURE: A 25-gauge pars plana vitrectomy, removal of intraocular gas, re-formation of anterior chamber, synechialysis, and surgical peripheral iridectomy, all in the right eye.
SURGEON: xxxxxxxxx MD
ANESTHESIA: Monitored anesthesia care with a retrobulbar block.
ESTIMATED BLOOD LOSS: Less than 1 mL.
COMPLICATIONS: None.
PROCEDURE: The right eye of Mr. xxxxxx was prepped and draped in a sterile fashion, after which a standard 3-port 25-gauge pars plana vitrectomy setup was placed. A back-flush needle was used to remove C3F8 from the eye, and the infusion was clamped. Three paracentesis ports were created at 1 o'clock, 8 o'clock, and 10 o'clock, through which viscoelastic (Provisc) was used to re-form the anterior chamber and to lyse 360 degree posterior synechiae adhering the iris to the posterior chamber lens. The infusion was then opened, and the vitrectomy cutter was used to create an inferior peripheral iridectomy at 5:30. Once the iridectomy was confirmed to be patent, attention was turned posteriorly. A 360-degree examination revealed a fully attached retina. A macular lens was placed on the eye, and examination of the macular showed the full-thickness macular hole to be closed. Any residual debris was removed from the eye using the vitrectomy cutter. The infusion was then again clamped, and balanced saline solution was used to irrigate free any residual viscoelastic in the anterior chamber. The peripheral iridectomy was seen to be patent, and the iris was mobile. One final examination was performed of the posterior segment, which was seen to be free of blood and debris with a flat macula.
The vitrectomy cannulae were then removed, and the sclerotomies were sutured with interrupted 6-0 Vicryl stitches. The anterior chamber was re-pressurized with balanced saline solution, and the paracentesis ports were hydrated. The eye was seen to be well pressurized but soft. The lid speculum and drapes were removed, and the eye was patched and shielded with Cyclogyl drops and TobraDex ointment. The patient returned to the postoperative area in stable condition.
>
PRELIMINARY REPORT UNTIL ELECTRONICALLY SIGNED BY PHYSICIAN
DICTATING PHYSICAN: xxxxxxxxx MD
ESIGNING PHYSICIAN:
ESIGN DATE AND TIME:
CC:
Pomerleau,Dustin L MD
DD: 03/27/13 1823 TI: SYN
DT: 03/28/13 0739 LC: 48
