Please help with the op note below. I posted this under ASC but did not receive any comments, so I thought I would try here. I was looking @ 67974, 15260, 21282 plus excision code - Doc office used 15260, 21282 and 67917. Thanks in advance for any suggestions.

PREOPERATIVE DIAGNOSIS: Basal cell carcinoma of the left lower lid.

POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma of the left lower lid.

OPERATION PERFORMED: 1. Musculocutaneous advancement flap of the left upper lid and lower lid, CPT 15732.
2. Full thickness skin graft from the right upper lid to the right lower lid.
3. Lateral canthal reconstruction.
4. Intramarginal adhesion.



ANESTHESIOLOGIST: Per Anesthesia Service.

SPECIMENS: A through S finally resulting in resection of about 80% of the lower eyelid. Final margins negative for tumor.

INDICATIONS: The patient has a biopsy-proven basal cell carcinoma that requires definitive resection. The risks of surgery were discussed with her which included bleeding, infection, poor cosmetic outcome and need for additional surgery. She understands and accepts.

OPERATIVE PROCEDURE: After informed consent, she was brought to the operating room and placed in the supine position whereupon time out was performed and confirmed correct patient and correct surgery identified. Then, 2% lidocaine with 1:100,000 epinephrine was injected into the left lower lid.

The first section was taken where it all turned out to be positive until finally the last section which was a full thickness with resection including about 8% of the lower eyelid was negative for tumor. When final margins were negative, reconstruction commenced.

A pedicle flap from the left upper lid was rotated downward to the level of the lower lids. A tarsal plate was then transferred in the conjunctival buccal flap. This was then positioned with multiple 5-0 Vicryl sutures. The skin graft was harvested from the right upper lid and transferred to the left lower lid and centered position with multiple 5-0 fast. A canthotomy cantholysis was performed to reconstruct the lateral canthal tendon and a 4-0 PDS suture on a P2 half round needle was then used to reseal the lower to the upper lid and resuspend it above Whitnall’s tubercle from the lateral orbital rim. The skin incision laterally was then closed with the 5-0 nylon. The intramarginal adhesions were also performed with the 5-0 nylon.

At the conclusion, the pathology was entirely negative. Pedicle flaps were sealed in place. Pressure bandage was placed on the wound.

She was then taken to recovery in stable condition. She will follow up Monday for removal of bandage.