idjimenez
Contributor
I need help with finding the accurate code for this procedure. I was thinking of using the malignant excision codes; the 16_ _ _
Physician stated:
OPERATIONS: Wide excision of the left cheek and lower eyelid and reconstruction with Integra, Frost suture left lower eyelid
PROCEDURE: She was brought to the operating room and underwent induction of general oral endotracheal anesthesia, after which all pressure points were appropriately padded and the table was turned 90 degrees. Intraoral examination was negative on inspection and palpation, and the lower eyelid had essentially a 1-cm grossly negative margin under the lashes. The conjunctiva was negative on gross examination. A wide excision to the nasal sidewall, nasolabial fold, lower eyelashes and lateral cheek were marked, and a traction suture was placed on the lower eyelid to be used as a Frost suture. The excision was then performed as diagrammed and carried through the subcutaneous tissue, which appeared to be grossly negative and this was carried down to the periosteum. Excision was continued in this layer, and the maxillary division of the trigeminal nerve was sacrificed. The lesion was then oriented with sutures and sent to Pathology. Hemostasis was maintained, and the surgical site was irrigated. Integra was then placed in the saline and ultimately transferred to the wound where it was trimmed and secured using interrupted 4-0 nylon sutures, which were then used to secure a tie-over bolster. She tolerated the procedure well, and the Frost suture was carefully secured to the forehead. The Frost suture was at the temporal limbus of the iris. The eye was irrigated with BSS, and she was extubated and returned to the Postanesthesia Care Unit in satisfactory and stable condition.
Physician stated:
OPERATIONS: Wide excision of the left cheek and lower eyelid and reconstruction with Integra, Frost suture left lower eyelid
PROCEDURE: She was brought to the operating room and underwent induction of general oral endotracheal anesthesia, after which all pressure points were appropriately padded and the table was turned 90 degrees. Intraoral examination was negative on inspection and palpation, and the lower eyelid had essentially a 1-cm grossly negative margin under the lashes. The conjunctiva was negative on gross examination. A wide excision to the nasal sidewall, nasolabial fold, lower eyelashes and lateral cheek were marked, and a traction suture was placed on the lower eyelid to be used as a Frost suture. The excision was then performed as diagrammed and carried through the subcutaneous tissue, which appeared to be grossly negative and this was carried down to the periosteum. Excision was continued in this layer, and the maxillary division of the trigeminal nerve was sacrificed. The lesion was then oriented with sutures and sent to Pathology. Hemostasis was maintained, and the surgical site was irrigated. Integra was then placed in the saline and ultimately transferred to the wound where it was trimmed and secured using interrupted 4-0 nylon sutures, which were then used to secure a tie-over bolster. She tolerated the procedure well, and the Frost suture was carefully secured to the forehead. The Frost suture was at the temporal limbus of the iris. The eye was irrigated with BSS, and she was extubated and returned to the Postanesthesia Care Unit in satisfactory and stable condition.