dyoungberg
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Good Morning! I need assistance in coding the following surgery.
PREOP DIAGNOSIS: TUMOR RIGHT ORBIT
POSTOP DIAGNOSIS: SAME
PROCEDURE: RESECTION OF TUMOR RIGHT ORBIT WITH CANTHOPLASTY AND REINSERTION OF INFERIOR OBLIQUE MUSCLE
COMPLICATIONS: NONE
OPERATIVE FINDINGS: There was an oval 4.0 x 2.5 cm beefy tumor involving the floor of the right orbit and the inferior oblique muscle immediately inferior to the ocular globe on the right.
PROCEDURE: Under general anesthesia the patient was prepped and draped in a sterile manner in order to give good exposure to the face. The right periorbital area was infiltrated with about 5 cc Lidocaine 1% with epinephrine 1:100,000. The Colorado bovie was then used to make a subciliary incision along the entire length of the lower eyelid, through the skin and orbicularis oris muscle and the lateral canthal area extending to the orbital rim down a crow's foot. A skin-muscle flap was raised and the septum transected about midway between the globe and the inferior orbital rim. A layer of fat was then dissected free from the underlying tumor which was then carefully dissected away from the globe. The tumor was found to be densely adherent to the inferior oblique muscle. The muscle was transected and the tumor dissected free from the involved portion of the muscle. The oblique muscle was sutured later in the procedure back down to the inferior orbital rim at about the 6 o'clock position. The tumor was then further dissected posteriorly away from the surrounding periorbita and removed. It was sent for frozen section histoanalysis. Several small bleeders were bovie cauterized during the procedure. The orbicularis muscle at the superior lateral corner was then sutured back to the lateral canthal tendon using 5-0 Rapide. The orbicularis muscle in this area was sutured back in a normal anatomic position with the same material. The skin was then closed with 6-0 nylon and Polysporin ointment applied. The patient was awakened and returned to the recovery room in stable condition.
Frozen section histoanalysis revealed probable lymphoma.
I haven't been able to come up with a code for the resection so I'm thinking perhaps an unlisted code. 67950 can be used for the canthoplasty, but I'm really stumped on this. Any takers?
PREOP DIAGNOSIS: TUMOR RIGHT ORBIT
POSTOP DIAGNOSIS: SAME
PROCEDURE: RESECTION OF TUMOR RIGHT ORBIT WITH CANTHOPLASTY AND REINSERTION OF INFERIOR OBLIQUE MUSCLE
COMPLICATIONS: NONE
OPERATIVE FINDINGS: There was an oval 4.0 x 2.5 cm beefy tumor involving the floor of the right orbit and the inferior oblique muscle immediately inferior to the ocular globe on the right.
PROCEDURE: Under general anesthesia the patient was prepped and draped in a sterile manner in order to give good exposure to the face. The right periorbital area was infiltrated with about 5 cc Lidocaine 1% with epinephrine 1:100,000. The Colorado bovie was then used to make a subciliary incision along the entire length of the lower eyelid, through the skin and orbicularis oris muscle and the lateral canthal area extending to the orbital rim down a crow's foot. A skin-muscle flap was raised and the septum transected about midway between the globe and the inferior orbital rim. A layer of fat was then dissected free from the underlying tumor which was then carefully dissected away from the globe. The tumor was found to be densely adherent to the inferior oblique muscle. The muscle was transected and the tumor dissected free from the involved portion of the muscle. The oblique muscle was sutured later in the procedure back down to the inferior orbital rim at about the 6 o'clock position. The tumor was then further dissected posteriorly away from the surrounding periorbita and removed. It was sent for frozen section histoanalysis. Several small bleeders were bovie cauterized during the procedure. The orbicularis muscle at the superior lateral corner was then sutured back to the lateral canthal tendon using 5-0 Rapide. The orbicularis muscle in this area was sutured back in a normal anatomic position with the same material. The skin was then closed with 6-0 nylon and Polysporin ointment applied. The patient was awakened and returned to the recovery room in stable condition.
Frozen section histoanalysis revealed probable lymphoma.
I haven't been able to come up with a code for the resection so I'm thinking perhaps an unlisted code. 67950 can be used for the canthoplasty, but I'm really stumped on this. Any takers?