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Reading this operative report what code would you choose ?
Postoperative Diagnosis: Levator ptosis right upper lid.
Operation: Levator repair of the ptosis of the right upper lid.
Procedure:
The patient had an IV started. She was brought to operating room and placed on the table in a supine position. Anesthesia monitoring devices were attached. IV sedation was then given. The right upper lid was numbed with a mixture of 0.5% Marcaine mixed with 2% lidocaine with epinephrine. Approximately 4 cc was used. The whole upper half of the face was then prepped and draped in the usual sterile fashion. A skin marking pen was used to mark a small crescent of skin to be removed from the upper lid on the right side.This was then covered with #15v blade down to the level of orbicularis. The skin was removed with Westcott scissors. The tissue was then turned out between forceps and using Westcott scissors and incision down to the orbital septum was made. Further dissection left and right exposed the levator apparatus and aponeurosis. Further dissection was made inferiorly exposing the tarsus. Reaching up with forceps into the area of the levator aponeurosis, the muscle action was identified by the patient looking up and down. This area was then captured with 5-0 Vicryl suture. A pass of teh same suture was then made at the superior middle aspect of the tarsus. In a similar fashion, two more passes between the levator and the tarsus were performed both medially and laterally. All the sutures were pulled out tight and tied with slip knots to check the lid position, which was good. The knots sewed and tied permanently and ends cut short. Intermediate layers were closed with several 5-0 Vicryl sutures placed in an interrupted fashion. The skin layer was then closed with a running subcuticular 6-0 Prolene with loops at both ends. The patient was then undraped. She was cleaned up. Silverdex ointment ws placed on the incision on the eye and ice pack was applied.
when you choose a code, what is the key word in operative report that made you choose ? thanks trent
Postoperative Diagnosis: Levator ptosis right upper lid.
Operation: Levator repair of the ptosis of the right upper lid.
Procedure:
The patient had an IV started. She was brought to operating room and placed on the table in a supine position. Anesthesia monitoring devices were attached. IV sedation was then given. The right upper lid was numbed with a mixture of 0.5% Marcaine mixed with 2% lidocaine with epinephrine. Approximately 4 cc was used. The whole upper half of the face was then prepped and draped in the usual sterile fashion. A skin marking pen was used to mark a small crescent of skin to be removed from the upper lid on the right side.This was then covered with #15v blade down to the level of orbicularis. The skin was removed with Westcott scissors. The tissue was then turned out between forceps and using Westcott scissors and incision down to the orbital septum was made. Further dissection left and right exposed the levator apparatus and aponeurosis. Further dissection was made inferiorly exposing the tarsus. Reaching up with forceps into the area of the levator aponeurosis, the muscle action was identified by the patient looking up and down. This area was then captured with 5-0 Vicryl suture. A pass of teh same suture was then made at the superior middle aspect of the tarsus. In a similar fashion, two more passes between the levator and the tarsus were performed both medially and laterally. All the sutures were pulled out tight and tied with slip knots to check the lid position, which was good. The knots sewed and tied permanently and ends cut short. Intermediate layers were closed with several 5-0 Vicryl sutures placed in an interrupted fashion. The skin layer was then closed with a running subcuticular 6-0 Prolene with loops at both ends. The patient was then undraped. She was cleaned up. Silverdex ointment ws placed on the incision on the eye and ice pack was applied.
when you choose a code, what is the key word in operative report that made you choose ? thanks trent
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