CLICLEMME
New
I think 30580 for this but what about the flaps? I am not sure that is included in the surgery and if not what code to use. None of them really match up?
DIAGNOSIS: Palatal fistula History of Jaw surgery POSTOP DIAGNOSIS: Palatal fistula History of Jaw surgery ESTIMATED BLOOD LOSS: N/A SPECIMENS REMOVED: N/A PROCEDURE: This woman is known to us. We planned the above-mentioned procedures, consented, brought the OR, laid supine on the table, induced under anesthesia, prepped and draped in the usual standard and sterile fashion. Began by placing a mouth gag retractor, the Dingman style. We accessed the fistula which was under 1cm on the Left hard palate. We drew two lines for relaxing incisions on either side of the fistula. We injected local with epinephrine. Then we raised two mucoperiosteal flaps and undermined them widely. We developed 2 flaps on the nasal side as well. We pushed the nasal tissue up and closed it. We then inset tissue between the oral flaps, or tissue membrane variety. And then advanced the oral flaps over top for closure. Donor sites were closed. The mouth was suctioned. She was turned back roused and taken to recover in stable condition. I was present and scrubbed for the entire operation.
DIAGNOSIS: Palatal fistula History of Jaw surgery POSTOP DIAGNOSIS: Palatal fistula History of Jaw surgery ESTIMATED BLOOD LOSS: N/A SPECIMENS REMOVED: N/A PROCEDURE: This woman is known to us. We planned the above-mentioned procedures, consented, brought the OR, laid supine on the table, induced under anesthesia, prepped and draped in the usual standard and sterile fashion. Began by placing a mouth gag retractor, the Dingman style. We accessed the fistula which was under 1cm on the Left hard palate. We drew two lines for relaxing incisions on either side of the fistula. We injected local with epinephrine. Then we raised two mucoperiosteal flaps and undermined them widely. We developed 2 flaps on the nasal side as well. We pushed the nasal tissue up and closed it. We then inset tissue between the oral flaps, or tissue membrane variety. And then advanced the oral flaps over top for closure. Donor sites were closed. The mouth was suctioned. She was turned back roused and taken to recover in stable condition. I was present and scrubbed for the entire operation.