vmounce
Guru
Can someone look at the report below? I think cpt code 67311, office says 67312. I appreciate any information.
Thanks,
Vickie
PREOPERATIVE DIAGNOSIS: Constant esotropia.
POSTOPERATIVE DIAGNOSIS: Constant esotropia.
PROCEDURE: Bilateral medial rectus recession.
INDICATIONS: The patient is a 14-year-old girl who presented to the eye clinic stating that her eye turns inward and this bothers her. On exam, she was found to have a 14 to 16 prism esotropia of the left eye in primary gaze with her glasses on. The benefits, risks, and alternatives of bilateral medial rectus recession were explained in detail to Melissa and informed consent was obtained.
OPERATIVE PROCEDURE: I identified the patient in the preoperative holding area and she was then taken to the operative suite and placed in the supine position where anxiolysis was administered intravenously without complications. General endotracheal anesthesia was then undertaken by the anesthesia team without complications. The eyes prepped in the standard sterile fashion for ophthalmic surgery.
Attention was turned first to the right eye where Tegaderm was placed to hold back the lashes and a lid speculum was placed. Forced duction testing was done by using the locking 0.5 Castroviejo forceps and torting the eye left and right. There was no restriction of the eye. The eye was then torted with the same forceps superotemporally and approximately an 8 mm conjunctival peritomy was performed in the inferonasal fornix. Tenon's was then incised perpendicular to the conjunctival incision. A small Green hook was used to grasp the medial rectus muscle. Two large hooks were then used to grasp the muscle to assure that all muscle fibers were obtained on the hook.
The small hook was used to retract Tenon's and conjunctiva over the end of the larger hook and then the intramuscular septum was incised from the muscle insertion at the sclera. Handheld cautery was used for hemostasis. CTAs were used for blunt dissection of the muscle. A double-armed 6-0 Vicryl suture was passed through the muscle approximately 1 mm from the insertion site and locked at both ends of the muscle. Tenotomy scissors were used to excise the muscle from the sclera. The muscle was inspected on the suture and found to be totally obtained. 0.5 locking Castroviejo forceps were used to grab the sclera at the point at the original muscle insertion and then calipers were used to mark 3.0 mm back from the original muscle insertion site on the sclera. The needles were passed through the sclera one-half thickness in a cross-swords fashion. The muscle was tied down to the new insertion site 3.0 mm back. It was carefully inspected and there were no adhesions or any problems. The muscle was nicely seated. The conjunctiva was closed with three interrupted 6-0 Vicryl sutures. Erythromycin ointment was placed in the eye.
Attention was turned to the left eye where an identical procedure without complications or deviations was performed.
The patient was awakened from general endotracheal anesthesia without problems. She had only very minor bleeding during the procedure. The patient will put Erythromycin ointment three times day in both eyes as explained to her mother. She will follow up with me in one week or sooner if she has any problems as I have explained to the parents and grandparents
Thanks,
Vickie
PREOPERATIVE DIAGNOSIS: Constant esotropia.
POSTOPERATIVE DIAGNOSIS: Constant esotropia.
PROCEDURE: Bilateral medial rectus recession.
INDICATIONS: The patient is a 14-year-old girl who presented to the eye clinic stating that her eye turns inward and this bothers her. On exam, she was found to have a 14 to 16 prism esotropia of the left eye in primary gaze with her glasses on. The benefits, risks, and alternatives of bilateral medial rectus recession were explained in detail to Melissa and informed consent was obtained.
OPERATIVE PROCEDURE: I identified the patient in the preoperative holding area and she was then taken to the operative suite and placed in the supine position where anxiolysis was administered intravenously without complications. General endotracheal anesthesia was then undertaken by the anesthesia team without complications. The eyes prepped in the standard sterile fashion for ophthalmic surgery.
Attention was turned first to the right eye where Tegaderm was placed to hold back the lashes and a lid speculum was placed. Forced duction testing was done by using the locking 0.5 Castroviejo forceps and torting the eye left and right. There was no restriction of the eye. The eye was then torted with the same forceps superotemporally and approximately an 8 mm conjunctival peritomy was performed in the inferonasal fornix. Tenon's was then incised perpendicular to the conjunctival incision. A small Green hook was used to grasp the medial rectus muscle. Two large hooks were then used to grasp the muscle to assure that all muscle fibers were obtained on the hook.
The small hook was used to retract Tenon's and conjunctiva over the end of the larger hook and then the intramuscular septum was incised from the muscle insertion at the sclera. Handheld cautery was used for hemostasis. CTAs were used for blunt dissection of the muscle. A double-armed 6-0 Vicryl suture was passed through the muscle approximately 1 mm from the insertion site and locked at both ends of the muscle. Tenotomy scissors were used to excise the muscle from the sclera. The muscle was inspected on the suture and found to be totally obtained. 0.5 locking Castroviejo forceps were used to grab the sclera at the point at the original muscle insertion and then calipers were used to mark 3.0 mm back from the original muscle insertion site on the sclera. The needles were passed through the sclera one-half thickness in a cross-swords fashion. The muscle was tied down to the new insertion site 3.0 mm back. It was carefully inspected and there were no adhesions or any problems. The muscle was nicely seated. The conjunctiva was closed with three interrupted 6-0 Vicryl sutures. Erythromycin ointment was placed in the eye.
Attention was turned to the left eye where an identical procedure without complications or deviations was performed.
The patient was awakened from general endotracheal anesthesia without problems. She had only very minor bleeding during the procedure. The patient will put Erythromycin ointment three times day in both eyes as explained to her mother. She will follow up with me in one week or sooner if she has any problems as I have explained to the parents and grandparents