dyoungberg
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When doctor performs lateral canthal tendon tightening of all four lids, what is the proper coding? I have chosen 67917 (based on the op note) with modifier 50. But can we bill for all 4 lids and how would I do that?
Here is the Op Note:
POSTOPERATIVE DIAGNOSIS:
1. ECTROPION ALL FOUR LIDS
2. DERMATOCHALASIS, BOTH UPPER LIDS
3. PTOSIS, BOTH UPPER LIDS
PROCEDURE:
1. LATERAL CANTHAL TENDON TIGHTENING (BICK PROCEDURE), ALL FOUR LIDS
2. BLEPHAROPLASTY BILATERAL UPPER LID
3. PTOSIS REPAIR BY EXTERNAL LEVATOR APPROACH BOTH UPPER LIDS
ANESTHESIA: MAC
INDICATIONS FOR PROCEDURE: This patient had functional obstruction of upper field of view due in both eyes, demonstrated by diminished marginal reflex distance and functional visual field obstruction on formal field testing and has extremely floppy tarsus in all four lids with ectropion on the lower lids and ectropion and eversion of the upper lids. With all these things, we planned four lid lateral canthal tightening procedures as well as ptosis repair and blepharoplasty on the upper lids.
DESCRIPTION OF PROCEDURE: After identifying patient, procedure and operative site, we drew a surgical ellipse in the upper lids in both eyes and then a lower subciliary incision of the lower lids in both eyes and then sedated the patient and gave him a block with Lidocaine and epinephrine. He had ice applied to the lids for about 20 minutes.
He was then brought to the operative suite, prepped in the usual fashion and draped with a split sheet and we initially addressed the left eye lower lid where we made the subciliary incisions, freed the skin/muscle flap inferiorly and then released the lower crus of the lateral canthal tendon.
We then released lower lid retractors with Westcott scissors and then fashioned the lateral tarsal strip. We then placed a 5-0 polyester nonabsorbable suture through this in a double arm fashion, cleared the lateral orbital rim and then fashioned through the lateral orbital rim periosteum a double bite of this material once this was tied we did a similar procedure in the upper lid where we freed the upper lid laterally, removed a section of the lateral tarsus entirely by resection and then fashioned the lateral tarsal strip of the remaining portion. We placed the same 5-0 polyester suture, double arm, through this tarsal strip and then up through the periosteum of the lateral orbital rim. The resected portion of the tarsus was at least 5 mm and this was, of course, discarded. The lateral canthal tendon area was reconstructed, joining the upper and lower lids with a 5-0 Vicryl suture and then joining the lateral raphe of the upper and lower orbicularis tissues down to the periosteum. We pulled some of the lower lid orbicularis upward with this. Next we closed the skin in the subciliary area and then up through the lower lid to the lateral upper lid area.
Once this was completed we found the entire upper lid had been transposed laterally so much that the previously drawn ellipse was no longer in the proper position, so we redrew it with the patient on the table with a marking pen and then excised skin/muscle flap in the upper lids. We were careful going through the very thin tissue of the upper lids. There was almost no central fat pad notable. We removed some nasal fat pad and then we tried finding the levator. There was really no levator complex in either aponeurosis nor muscular portion in this eye. It had undergone extensive fat atrophy and that is all we found where the levator was to be. We cleaned the anterior tarsal surface which itself was smaller than usual and floppy and then anchored a 6-0 black silk to the tarsus and up through what would have been the remnants of this atrophic degenerated levator and tried to lift the lid as much as we could and tied this down in a fashion that looked like it opened somewhat and closed somewhat. Then we closed the skin with a running 6-0 nylon and removed a dog-ear nasally.
The right eye was then performed in the same fashion. We started with the lower lid, making the subciliary incision, freeing the lower lid skin/muscle flap and then releasing the lower crus of the lateral canthal tendon and then releasing lower lid retractors and freeing the tarsal strip laterally so it can be secured back to the periosteum. Pleated and double armed 5-0 polyester sutures passed through this and then through the lateral orbital rim, periosteum and these sutures were left while the upper lid was addressed.
We released the upper crus lateral canthal tendon. We released the lateral portion of the upper lid and then resected at least 4 or 5 mm of tarsus horizontally. We then made a tarsal strip of what remained of the tarsus superiorly and with double armed polyester suture through this we again passed it through the orbital rim periosteum. All four of these sutures were then tied and they looked like they had the lid in good position and the laxity of the extreme floppy tarsus was alleviated.
Next the lateral canthus was reconstructed using a 5-0 Vicryl suture at the canthus and then the skin was closed with 6-0 nylon in a fashion, closing it entirely from subciliary incision up through the lower lid and upper lid areas. Just before closing the skin, we did reconstruct the lateral raphe by pulling orbicularis upward and downward respectively and attaching them to the lateral canthus at the periosteum.
Next we again looked and the ellipse had been moved laterally in the upper lid from where it had previously been marked, so we remarked it and excised the skin/muscle flap appropriately, again carefully dissected without cautery through the septum and found a very small central fat pad and a moderately large nasal fat pad which was resected. We again found the levator complex to have undergone extensive fat atrophy. It had no tone pulling up or down while we were trying to get him to look and so we did as we could and, with cleaning of the anterior tarsal and securing a 6-0 black silk through this, we double arm passed up through this levator atrophic complex, tightened it somewhat. It seemed to open similar to the other eye and we tied it down at that point. We closed the lid with a 6-0 nylon and a dog-ear removal nasally and the patient wen to the recovery room with ice packs on his eyes, having tolerated this extremely complex and long procedure, taking just under 2 hours.
Thanks!
Debbie
NW FL Surgery Center
Here is the Op Note:
POSTOPERATIVE DIAGNOSIS:
1. ECTROPION ALL FOUR LIDS
2. DERMATOCHALASIS, BOTH UPPER LIDS
3. PTOSIS, BOTH UPPER LIDS
PROCEDURE:
1. LATERAL CANTHAL TENDON TIGHTENING (BICK PROCEDURE), ALL FOUR LIDS
2. BLEPHAROPLASTY BILATERAL UPPER LID
3. PTOSIS REPAIR BY EXTERNAL LEVATOR APPROACH BOTH UPPER LIDS
ANESTHESIA: MAC
INDICATIONS FOR PROCEDURE: This patient had functional obstruction of upper field of view due in both eyes, demonstrated by diminished marginal reflex distance and functional visual field obstruction on formal field testing and has extremely floppy tarsus in all four lids with ectropion on the lower lids and ectropion and eversion of the upper lids. With all these things, we planned four lid lateral canthal tightening procedures as well as ptosis repair and blepharoplasty on the upper lids.
DESCRIPTION OF PROCEDURE: After identifying patient, procedure and operative site, we drew a surgical ellipse in the upper lids in both eyes and then a lower subciliary incision of the lower lids in both eyes and then sedated the patient and gave him a block with Lidocaine and epinephrine. He had ice applied to the lids for about 20 minutes.
He was then brought to the operative suite, prepped in the usual fashion and draped with a split sheet and we initially addressed the left eye lower lid where we made the subciliary incisions, freed the skin/muscle flap inferiorly and then released the lower crus of the lateral canthal tendon.
We then released lower lid retractors with Westcott scissors and then fashioned the lateral tarsal strip. We then placed a 5-0 polyester nonabsorbable suture through this in a double arm fashion, cleared the lateral orbital rim and then fashioned through the lateral orbital rim periosteum a double bite of this material once this was tied we did a similar procedure in the upper lid where we freed the upper lid laterally, removed a section of the lateral tarsus entirely by resection and then fashioned the lateral tarsal strip of the remaining portion. We placed the same 5-0 polyester suture, double arm, through this tarsal strip and then up through the periosteum of the lateral orbital rim. The resected portion of the tarsus was at least 5 mm and this was, of course, discarded. The lateral canthal tendon area was reconstructed, joining the upper and lower lids with a 5-0 Vicryl suture and then joining the lateral raphe of the upper and lower orbicularis tissues down to the periosteum. We pulled some of the lower lid orbicularis upward with this. Next we closed the skin in the subciliary area and then up through the lower lid to the lateral upper lid area.
Once this was completed we found the entire upper lid had been transposed laterally so much that the previously drawn ellipse was no longer in the proper position, so we redrew it with the patient on the table with a marking pen and then excised skin/muscle flap in the upper lids. We were careful going through the very thin tissue of the upper lids. There was almost no central fat pad notable. We removed some nasal fat pad and then we tried finding the levator. There was really no levator complex in either aponeurosis nor muscular portion in this eye. It had undergone extensive fat atrophy and that is all we found where the levator was to be. We cleaned the anterior tarsal surface which itself was smaller than usual and floppy and then anchored a 6-0 black silk to the tarsus and up through what would have been the remnants of this atrophic degenerated levator and tried to lift the lid as much as we could and tied this down in a fashion that looked like it opened somewhat and closed somewhat. Then we closed the skin with a running 6-0 nylon and removed a dog-ear nasally.
The right eye was then performed in the same fashion. We started with the lower lid, making the subciliary incision, freeing the lower lid skin/muscle flap and then releasing the lower crus of the lateral canthal tendon and then releasing lower lid retractors and freeing the tarsal strip laterally so it can be secured back to the periosteum. Pleated and double armed 5-0 polyester sutures passed through this and then through the lateral orbital rim, periosteum and these sutures were left while the upper lid was addressed.
We released the upper crus lateral canthal tendon. We released the lateral portion of the upper lid and then resected at least 4 or 5 mm of tarsus horizontally. We then made a tarsal strip of what remained of the tarsus superiorly and with double armed polyester suture through this we again passed it through the orbital rim periosteum. All four of these sutures were then tied and they looked like they had the lid in good position and the laxity of the extreme floppy tarsus was alleviated.
Next the lateral canthus was reconstructed using a 5-0 Vicryl suture at the canthus and then the skin was closed with 6-0 nylon in a fashion, closing it entirely from subciliary incision up through the lower lid and upper lid areas. Just before closing the skin, we did reconstruct the lateral raphe by pulling orbicularis upward and downward respectively and attaching them to the lateral canthus at the periosteum.
Next we again looked and the ellipse had been moved laterally in the upper lid from where it had previously been marked, so we remarked it and excised the skin/muscle flap appropriately, again carefully dissected without cautery through the septum and found a very small central fat pad and a moderately large nasal fat pad which was resected. We again found the levator complex to have undergone extensive fat atrophy. It had no tone pulling up or down while we were trying to get him to look and so we did as we could and, with cleaning of the anterior tarsal and securing a 6-0 black silk through this, we double arm passed up through this levator atrophic complex, tightened it somewhat. It seemed to open similar to the other eye and we tied it down at that point. We closed the lid with a 6-0 nylon and a dog-ear removal nasally and the patient wen to the recovery room with ice packs on his eyes, having tolerated this extremely complex and long procedure, taking just under 2 hours.
Thanks!
Debbie
NW FL Surgery Center