andrewsbev23
Guest
I have some confusion with the following operative report. The surgeon is designating 30118. I'm not sure that covers everything done especially the graft. My Ingenix companion says that no post op wound closure is necessary. Can someone please give me some insight. Thanks for any help!! 
Here is the note: The patient was brought to the operating room and placed on the operating room table in supine position. After confirming the patient's identity and procedure, general anesthesia was induced. The nasal sill was infiltrated with lidocaine 1% and 1:100,000 epinephrine, prepped with Betadine soap solution and draped in aseptic fashion. The previous skin graft was then incised in three quadrants anteromedially and laterally. The skin graft was then elevated off the deep tissues and pedicled posteriorly. A very deep excision was then performed of the entire deep margin extending to the bone near the nasal sill and approximately 4-5 mm in height anteriorly. It was sent for frozen section after being oriented. There was no residual tumor present. The skin graft was then set into position with interrupted 4-0 chromic sutures. It could not be closed down with mattress sutures. As a result, the bolster was replaced and consisted of two inch gauze in Xeroform and secured with a tie-over dressing of 3-0 Vicryl. The patient was allowed to emerge, extubated and taken to the recovery room having tolerated the procedure well.
Here is the note: The patient was brought to the operating room and placed on the operating room table in supine position. After confirming the patient's identity and procedure, general anesthesia was induced. The nasal sill was infiltrated with lidocaine 1% and 1:100,000 epinephrine, prepped with Betadine soap solution and draped in aseptic fashion. The previous skin graft was then incised in three quadrants anteromedially and laterally. The skin graft was then elevated off the deep tissues and pedicled posteriorly. A very deep excision was then performed of the entire deep margin extending to the bone near the nasal sill and approximately 4-5 mm in height anteriorly. It was sent for frozen section after being oriented. There was no residual tumor present. The skin graft was then set into position with interrupted 4-0 chromic sutures. It could not be closed down with mattress sutures. As a result, the bolster was replaced and consisted of two inch gauze in Xeroform and secured with a tie-over dressing of 3-0 Vicryl. The patient was allowed to emerge, extubated and taken to the recovery room having tolerated the procedure well.