PREOPERATIVE DX: Bilateral brow lid ptosis with dermatochalasis.
POSTOPERATIVE DX: same
OPERATIVE PROCEDURE: Bilateral brow lid blepharoplasty with ptosis repair.
Procedure: Patent was brought to the operating room and placed under sedation, prepped and draped in a sterile manner. Upper eyelids had been marked in the holding area and pinch test in the operating room was confirmed. Confirmed the skin removal. Beginning on the right, the skin was incised and removed. A small strip of orbicularis was then removed with tenotomy scissors medially. Dissection revealed a small bulge of nasal fat pad. This was then teased out and removed with bipolar cauterization after anesthetizing that with plain lidocaine. After this completed the levator mechanism was assessed. I made a small incision in the mid pupillary line through the septal tissue and dissection was carried down until the levator was identified confirming it with vertical muscle fiber visibility. An approximate 5-6 mm advancement was planned based on her degree of ptosis and the advancement was accomplished by placed a 6-0 Prolene suture in the tarsal plate and securing this to the levator at approximately the musculoaponeurotic junction as a mattress style suture. This was temporarily secured and attention was turned to the contralateral side where a similar process was completed. Once the levator suture was in placed on the left-hand side, she was sate upright and allowed to arouse to the following commands. With her opening and closing her eyes it was evident that she had slight reater tensioning on the right compared to the left side. The left side was suitable and right just had mild peaking. The right suture was adjusted accordinly and she was sat eupright again to confirm that she had good symmetric eyelid opening. The palpebral fissure distances were measured at approximately 9 mm after levator repair and at this point she was returned back to the supine positioning. The wounds were irrigated. Final hemostasis was ensured and then the muscle layer was approximated with 6-0 Prolene sutures.
Here is my question: Not sure which coding is most appropriate. Either 67900, 67900, 15823, 15823 or 67904?
Any help would be most appreciated.
Thank you.
POSTOPERATIVE DX: same
OPERATIVE PROCEDURE: Bilateral brow lid blepharoplasty with ptosis repair.
Procedure: Patent was brought to the operating room and placed under sedation, prepped and draped in a sterile manner. Upper eyelids had been marked in the holding area and pinch test in the operating room was confirmed. Confirmed the skin removal. Beginning on the right, the skin was incised and removed. A small strip of orbicularis was then removed with tenotomy scissors medially. Dissection revealed a small bulge of nasal fat pad. This was then teased out and removed with bipolar cauterization after anesthetizing that with plain lidocaine. After this completed the levator mechanism was assessed. I made a small incision in the mid pupillary line through the septal tissue and dissection was carried down until the levator was identified confirming it with vertical muscle fiber visibility. An approximate 5-6 mm advancement was planned based on her degree of ptosis and the advancement was accomplished by placed a 6-0 Prolene suture in the tarsal plate and securing this to the levator at approximately the musculoaponeurotic junction as a mattress style suture. This was temporarily secured and attention was turned to the contralateral side where a similar process was completed. Once the levator suture was in placed on the left-hand side, she was sate upright and allowed to arouse to the following commands. With her opening and closing her eyes it was evident that she had slight reater tensioning on the right compared to the left side. The left side was suitable and right just had mild peaking. The right suture was adjusted accordinly and she was sat eupright again to confirm that she had good symmetric eyelid opening. The palpebral fissure distances were measured at approximately 9 mm after levator repair and at this point she was returned back to the supine positioning. The wounds were irrigated. Final hemostasis was ensured and then the muscle layer was approximated with 6-0 Prolene sutures.
Here is my question: Not sure which coding is most appropriate. Either 67900, 67900, 15823, 15823 or 67904?
Any help would be most appreciated.
Thank you.