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coding for ectropion repair

  1. Default coding for ectropion repair
    Medical Coding Books
    could use help on this op report.

    Following the administration of local anesthesia, the pt was prepped and draped in the usual sterile ophthalmic fashion. The right lower eyelid was operated on first in the subscleral area. The incision ws made and carried laterally and then inferiorly at the orbital rim. This was dissected inferiorly to develop the skin muscle flap. the tarus was exposed. The tarus was clamped and cut. A section of 4mm was taken out. The tarus was anchored to the orbital rim using a 5-0 Nylon suture and secured to the orbital rim ina mattress fashion. The lower eyelid skin muscle flaps were created and was dissected inferiorly. The redundant orbital flap was prolapsed, clamped, and then cut. Hemostasis was obtained. Attention was then turned to the left lower eyelid, where the identical procedure was performed. The right lower eyelid was returned to. The eyelid margin was secured atthe corner of the incision laterally using interrupted 5-0 Vicryl sutured. The skin incision was then closed using a running 6-0 plain suture. Attention was next turned to the left lower eylid and the lateral margin of the eyelid was secured in place using interrupted 5-0 Vicryl sutures. Next the skin incision was closed using running 6-0 plain sutures as before. There were numerous lower eyelid nodules that were removed. the nodules were sent for pathology. Hemostasis was obtained. Eyelid position was inspected and noted to be pleasing. The pt tolerated the procedure well and left the operating room in good condition.

    My question does this documentation support a 67840, excision of eyelid w/o closure or w/ simple closure? 67917 E2
    67917 E4
    Physician does not state if nodules were on both lids or just one lid

  2. #2
    sounds like 67840. 67917 mentions tarsal strip operation. Also seems like its only on the lt eyelid. if not sure I would query the doc.

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