Jenannurb
Contributor
See operative note below.
my coworker and I are at an impasse with this one.We have two theories:
67966 which is based on the OP note heading
or
67840 which we feel is a better description
Any input would be appreciated!!
********
PREOPERATIVE DIAGNOSIS
Malignant Neoplasm Left Lower Lid
*
POSTOPERATIVE DIAGNOSIS
Malignant Neoplasm Left Lower Lid
*
PROCEDURE PERFORMED
Excision and Reconstruction of Eyelid Full Thickness involving the Margin 30% of Left Lower Eyelid
*
*
COMPLICATIONS
None.
*
ANESTHESIA
Local with monitored anesthesia care
*
Estimated Blood Loss: <10cc
*
Specimen: None
*
Implants: None
*
DESCRIPTION OF PROCEDURE
After obtaining informed consent, the patient was brought to the operating room. The patient was prepped and draped in the usual sterile fashion after the administration of local anesthesia. A 15 blade was used to excise a pentagon wedge around the suspicious lesion. Fresh frozen margins were obtained and confirmed the absence of any malignancy at the margins. The tarsal plate was closed using a 5-0 Vicryl suture followed by 6-0 silk sutures to approximate the lid margin. The skin edges were closed using interrupted 6-0 Plain gut sutures. At this point, the procedure was complete. The patient was returned to recovery in stable condition.[/COLOR]
my coworker and I are at an impasse with this one.We have two theories:
67966 which is based on the OP note heading
or
67840 which we feel is a better description
Any input would be appreciated!!
********
PREOPERATIVE DIAGNOSIS
Malignant Neoplasm Left Lower Lid
*
POSTOPERATIVE DIAGNOSIS
Malignant Neoplasm Left Lower Lid
*
PROCEDURE PERFORMED
Excision and Reconstruction of Eyelid Full Thickness involving the Margin 30% of Left Lower Eyelid
*
*
COMPLICATIONS
None.
*
ANESTHESIA
Local with monitored anesthesia care
*
Estimated Blood Loss: <10cc
*
Specimen: None
*
Implants: None
*
DESCRIPTION OF PROCEDURE
After obtaining informed consent, the patient was brought to the operating room. The patient was prepped and draped in the usual sterile fashion after the administration of local anesthesia. A 15 blade was used to excise a pentagon wedge around the suspicious lesion. Fresh frozen margins were obtained and confirmed the absence of any malignancy at the margins. The tarsal plate was closed using a 5-0 Vicryl suture followed by 6-0 silk sutures to approximate the lid margin. The skin edges were closed using interrupted 6-0 Plain gut sutures. At this point, the procedure was complete. The patient was returned to recovery in stable condition.[/COLOR]