would you just code 67312-50 or would you code this 67311 left- and 67312 rt, since 2 muscles was on right ?
POSTOPERATIVE DIAGNOSES: 1. Large right exotropia, 50 diopters. 2. Partial right third nerve palsy.
OPERATIONS: 1. Bilateral lateral rectus recessions, 8.5 right eye and 7.0 left eye. 2. Right medial rectus resection 5.0 mm.
PROCEDURE IN DETAIL:
The patient arrived to the operating room, was easily placed under general anesthesia without difficulty. He was prepped and draped in the usual fashion for extraocular muscle surgery.
An eyelid speculum was inserted under the eyelids of the right eye and 6-0 silk bridle sutures were placed at 6 o'clock and 12 o'clock. At the globe, forced ductions were performed indicating expected tightness of the right lateral rectus muscle. The globe was rotated nasally and a fornix-based conjunctival flap was fashioned laterally for approximately 60 degrees. The lateral rectus muscle was engaged and the tissue muscle was cleaned carefully with blunt and sharp dissection. Cautery was applied just anterior to the muscle insertion and two 6-0 Vicryl sutures were placed superiorly and inferiorly near the insertion. Each tissue was passed twice at one-third and one-fourth tendon width and tied with a 2-1 square knot. The muscle and tendon were then severed from the globe with Westcott scissors, and using calipers each suture was placed 8.5 mm posterior to the insertion. Each suture was tied with a 2-1-1 square knot. The conjunctiva was then replaced near the limbus with 6-0 catgut sutures. The globe was then rotated laterally and a similar incision and peritomy were made medially exposing the medial rectus muscle. This vessel was cleaned more than 10 mm and a double-armed 6-0 Vicryl suture was placed 5 mm from the insertion in the muscle. A central bite was initially made and tied with 2-1-1 square knot. Cautery was performed anterior to the suture placement in the muscle. The excess tendon and muscle were then excised and the sutures were placed superiorly and inferiorly through the muscle insertion and tunneled centrally in a crossed-swords fashion.
The incision was then tied approximating the muscles securely to the initial insertion site. An extra 6-0 Vicryl suture was placed to further secure the muscle and to prevent slippage. Conjunctiva was again restored in a similar fashion. At the end of this procedure, the forced ductions indicated equal resistance on adduction and abduction. Attention was then placed on the left eye where a 7.0 mm left lateral rectus recession was performed.
The patient tolerated the procedure extremely well and left the operating room in good condition.