ljhollis
Guest
Here is the op note:
Procedure: Sharp excisional debridement of an area down to the muscle measuring approximately 3 x 1.2 cm and a wedge excision with complex closure.
The patient was a male who was involved in a fight and his attacker bit off his lip. The defect extends from the vermillion border asll the way throught the muscle and the inside part of the patients mucosa. The patientst lower teether are clearly visible because the defect is so large. After informed consent was obtained the patient was placed on the OR table in the supine position. IV sedation was given and subsequently an LMA was placed in the oropharynx. The lower lip and facial area were all prepped and draped in the usual sterile fashion. A solution of half Marcaine and half ldodaine was used to locally anesthetize the area of the lip. A 15 blade was used to cut down through the skin which extended all the way down to the mental fold. The deeper layers of the muscl were also excised in a wedge fashion so as to allow for a better cosmetic outcome. The deep layers of the orbicularis oris and mentalis muscles were then approximated in layers and indidually using a 4-0 vicryl. The more superficial layers of the dermis were then reapproximated using a 5-0 vicryl. A 6-0 prolene was then used on the cuticular layer to reapproximate the superficial skn layers. Great care was taken around the vermillion border to try and align those layers up as best as possible. The inside part of the mucosa was also repaired using a 4-0 chromic. Sterile dressings were applied. The patient tolerated the procedure well there were no complications, he was transferred to recovery in stable condition.
Doc is saying he thinks this is a 15732, I am not sure if this is anything more than a complex closure. I know that debridement is included in a complex closure. I have never coded anything like this so any direction would be great. Thank you for you help.
Lori H, CPC
Procedure: Sharp excisional debridement of an area down to the muscle measuring approximately 3 x 1.2 cm and a wedge excision with complex closure.
The patient was a male who was involved in a fight and his attacker bit off his lip. The defect extends from the vermillion border asll the way throught the muscle and the inside part of the patients mucosa. The patientst lower teether are clearly visible because the defect is so large. After informed consent was obtained the patient was placed on the OR table in the supine position. IV sedation was given and subsequently an LMA was placed in the oropharynx. The lower lip and facial area were all prepped and draped in the usual sterile fashion. A solution of half Marcaine and half ldodaine was used to locally anesthetize the area of the lip. A 15 blade was used to cut down through the skin which extended all the way down to the mental fold. The deeper layers of the muscl were also excised in a wedge fashion so as to allow for a better cosmetic outcome. The deep layers of the orbicularis oris and mentalis muscles were then approximated in layers and indidually using a 4-0 vicryl. The more superficial layers of the dermis were then reapproximated using a 5-0 vicryl. A 6-0 prolene was then used on the cuticular layer to reapproximate the superficial skn layers. Great care was taken around the vermillion border to try and align those layers up as best as possible. The inside part of the mucosa was also repaired using a 4-0 chromic. Sterile dressings were applied. The patient tolerated the procedure well there were no complications, he was transferred to recovery in stable condition.
Doc is saying he thinks this is a 15732, I am not sure if this is anything more than a complex closure. I know that debridement is included in a complex closure. I have never coded anything like this so any direction would be great. Thank you for you help.
Lori H, CPC
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