Hi I'm new to coding this procedure and I wanted to get a second opinion on how I coded this note.
I REALLY APPRECIATE ANY FEEDBACK ON THIS NOTE!!
The DX is Pterygium
I coded 65780 and
V2790
The excision of the pterygium without out graft(65420) is inclusive to 65780
Here's the note:
After patient was identified and adequate peribulbar block, the patient was prepped and draped in sterile fashion. Correct surgical site was verified. Lid speculum is placed. This was followed by topical application of several drops of 1:1000 epinephrine to constrict blood vessels for subsequent hemostasis. Then 2% lidocaine gel was applied for topical anesthesia. Traction sutures are placed with 7-0 Vicryl at 6:00 and 12:00 o'clock. The eye is reflected temporally. This exposes the area of the pterygium plus excessive ocular scarring toward the medial canthus. Undr the microscope, the pterygium and the semilunar fold were identified. Using 0.12 forceps to pick up the semilunar fold, a peritomy was made in front of the semilunar fold and carried superiorly and inferiorly to the fornix. With the use of blunt and sharp dissection, the pterygium and fibroid vascular bundle is cleaned from the limbus and followed back toward the plica. Bleeding is managed with compression and wet field cautery. We then proceed to the head off the pterygium which is removed with combination of blunt and sharp dissection. Significant fibrous ocular tissue was dissected. Cornea surface smoothed using bur brush. Sealed gap with cautery. Layers of the amniotic membrane are required to reconstruct the ocular surface. This is done by cutting appropriate size strips of amniotic membrane, which are then glued with tissue glue in the appropriate areas. They are smoothed and found to be secure. We then approach the medial fibro vascular bundle. The amniotic membrane is then secured and smoothed out. It is tucked behind the free edges of conjunctiva. We then proceed to the corneal side to the dissection, where the amniotic membrane is additionally spread and glued to patch the corneal surface. Additional tissue glue is placed in the interface between the amniotic membrane and conjunctiva to further secure the amniotic membrane. A contact bandage was placed over the cornea. Patient tolerated the operation well. Thanks again
I REALLY APPRECIATE ANY FEEDBACK ON THIS NOTE!!
The DX is Pterygium
I coded 65780 and
V2790
The excision of the pterygium without out graft(65420) is inclusive to 65780
Here's the note:
After patient was identified and adequate peribulbar block, the patient was prepped and draped in sterile fashion. Correct surgical site was verified. Lid speculum is placed. This was followed by topical application of several drops of 1:1000 epinephrine to constrict blood vessels for subsequent hemostasis. Then 2% lidocaine gel was applied for topical anesthesia. Traction sutures are placed with 7-0 Vicryl at 6:00 and 12:00 o'clock. The eye is reflected temporally. This exposes the area of the pterygium plus excessive ocular scarring toward the medial canthus. Undr the microscope, the pterygium and the semilunar fold were identified. Using 0.12 forceps to pick up the semilunar fold, a peritomy was made in front of the semilunar fold and carried superiorly and inferiorly to the fornix. With the use of blunt and sharp dissection, the pterygium and fibroid vascular bundle is cleaned from the limbus and followed back toward the plica. Bleeding is managed with compression and wet field cautery. We then proceed to the head off the pterygium which is removed with combination of blunt and sharp dissection. Significant fibrous ocular tissue was dissected. Cornea surface smoothed using bur brush. Sealed gap with cautery. Layers of the amniotic membrane are required to reconstruct the ocular surface. This is done by cutting appropriate size strips of amniotic membrane, which are then glued with tissue glue in the appropriate areas. They are smoothed and found to be secure. We then approach the medial fibro vascular bundle. The amniotic membrane is then secured and smoothed out. It is tucked behind the free edges of conjunctiva. We then proceed to the corneal side to the dissection, where the amniotic membrane is additionally spread and glued to patch the corneal surface. Additional tissue glue is placed in the interface between the amniotic membrane and conjunctiva to further secure the amniotic membrane. A contact bandage was placed over the cornea. Patient tolerated the operation well. Thanks again