KristieStokesCPC
Expert
This is the op note from the physician:
DESCRIPTION OF PROCEDURE: This woman has had severe migraine headaches for a long time primarily supraorbital with pain over the zygomaticotemporal and the supraorbital nerve. Additionally, she has blepharospasm worse on the right than the left. She could not be treated with Botox because her family members had a severe allergic reaction to Botox. She has had 144 migraines in the last year and is truly disabled by her headaches.
Under satisfactory general anesthesia, she was appropriately identified and received 600 g of Cleocin intravenously. She is allergic to penicillin. She was intubated and the tube draped inferiorly. She was prepped with DuraPrep after placing Neosporin Ophthalmic Ointment in her eyes. She was draped in the appropriate manner.
The incision was planned in the right supratarsal crease and also in the left supratarsal crease to be identically placed and extended laterally in one of the smile lines. 0.25% Marcaine with 1:100,000 epinephrine was infiltrated into the skin, where the planned incisions were and then on the left side also in the region of the supraorbital nerve going up towards the corrugator. After allowing time for the anesthetic to take effect the epinephrine, the incision was made in an ellipse of skin of 5 mm at the widest was excised with underlying orbicularis muscle. Hemostasis was obtained throughout with the unipolar coagulator, which was guarded. Then going through the opening of orbicularis oculi muscle dissection went through the orbital septum to the orbital rim medially. Dissection was carried down until the supraorbital nerve was identified. It had a clear band compressed skin into a narrow supraorbital notch and the band was released. The nerve was white. Proximal to this, red and inflamed beneath the band and then became white again. The nerve was carefully followed and a segment of the corrugator muscle identified superficial to the nerve over approximately 1 cm. The muscle was cauterized and carefully excised taking care not to injure the nerve branches.
Now, the dissection was continued laterally and in the region of orbicularis oculi muscle, the muscle was divided longitudinally and horizontally. The muscle was elevated and by means of a stimulator, two small branches were identified and each was divided. They gave contractions in the muscle. This was to treat the blepharospasm.
Then, the orbital rim was identified and cauterized. The periosteum was incised and gently elevated going proximally and laterally until the zygomatic temporal branch was identified. Marcaine was infiltrated here just to fill the periosteal region and then the nerve was cauterized along with the
accompanying vessel. Hemostasis was checked again and found to be secured and the wound was ultimately closed with interrupted and continuous sutures of 6-0 nylon held in place with a Steri-Strip.
In the left side, just the small lateral extension of the incision was made and the identical procedure carried out on the left side for blepharospasm and the wound was closed in just with interrupted 6-0 nylon. She was awakened and transferred to the recovery in satisfactory condition. Dressings with Xeroform and more of the ophthalmic solution.
I get codes:
64719
64771
64742-rt
64742-lt...
any help would be appreciated. Thanks
DESCRIPTION OF PROCEDURE: This woman has had severe migraine headaches for a long time primarily supraorbital with pain over the zygomaticotemporal and the supraorbital nerve. Additionally, she has blepharospasm worse on the right than the left. She could not be treated with Botox because her family members had a severe allergic reaction to Botox. She has had 144 migraines in the last year and is truly disabled by her headaches.
Under satisfactory general anesthesia, she was appropriately identified and received 600 g of Cleocin intravenously. She is allergic to penicillin. She was intubated and the tube draped inferiorly. She was prepped with DuraPrep after placing Neosporin Ophthalmic Ointment in her eyes. She was draped in the appropriate manner.
The incision was planned in the right supratarsal crease and also in the left supratarsal crease to be identically placed and extended laterally in one of the smile lines. 0.25% Marcaine with 1:100,000 epinephrine was infiltrated into the skin, where the planned incisions were and then on the left side also in the region of the supraorbital nerve going up towards the corrugator. After allowing time for the anesthetic to take effect the epinephrine, the incision was made in an ellipse of skin of 5 mm at the widest was excised with underlying orbicularis muscle. Hemostasis was obtained throughout with the unipolar coagulator, which was guarded. Then going through the opening of orbicularis oculi muscle dissection went through the orbital septum to the orbital rim medially. Dissection was carried down until the supraorbital nerve was identified. It had a clear band compressed skin into a narrow supraorbital notch and the band was released. The nerve was white. Proximal to this, red and inflamed beneath the band and then became white again. The nerve was carefully followed and a segment of the corrugator muscle identified superficial to the nerve over approximately 1 cm. The muscle was cauterized and carefully excised taking care not to injure the nerve branches.
Now, the dissection was continued laterally and in the region of orbicularis oculi muscle, the muscle was divided longitudinally and horizontally. The muscle was elevated and by means of a stimulator, two small branches were identified and each was divided. They gave contractions in the muscle. This was to treat the blepharospasm.
Then, the orbital rim was identified and cauterized. The periosteum was incised and gently elevated going proximally and laterally until the zygomatic temporal branch was identified. Marcaine was infiltrated here just to fill the periosteal region and then the nerve was cauterized along with the
accompanying vessel. Hemostasis was checked again and found to be secured and the wound was ultimately closed with interrupted and continuous sutures of 6-0 nylon held in place with a Steri-Strip.
In the left side, just the small lateral extension of the incision was made and the identical procedure carried out on the left side for blepharospasm and the wound was closed in just with interrupted 6-0 nylon. She was awakened and transferred to the recovery in satisfactory condition. Dressings with Xeroform and more of the ophthalmic solution.
I get codes:
64719
64771
64742-rt
64742-lt...
any help would be appreciated. Thanks