Coding and Billing in the medical field
posted by Sadi Waye on .
1. Left orbitonasal mass.
2. Dry eye syndrome.
3. Pseudophakia, both eyes.
4. Computerized tomography confirmed tumor left orbital, left nasal side.
POSTOPERATIVE DIAGNOSES: Same with the addition of low-grade lymphoma, left orbit.
PROCEDURE: Anterior orbitotomy, debulking and biopsy.
ANESTHESIA: General endotracheal anaesthesia.
INDICATION: This 81-year-old white woman has had a progressively enlarging mass of the left superior nasal orbit, which had become quite hard and is attached to the bone. CT shows there has been no bony invasion, and the brain has not been invaded. More than likely, this is a lymphoma, but we want to take the patient for an anterior orbitotomy for debulking and biopsy.
DESCRIPTION OF PROCEDURE: After the patient was prepped and draped in the usual sterile fashion for ophthalmic surgery, the superior sulcus fold was marked out on her medial left upper lid. This was then cut through skin and muscle with the 25 Bard-Parker blade down through the orbital fat pad. It was noted there was some saponified fat and a hard mass that was kind of an orangeish-red color and was attached to this. Two specimens were removed and tagged and sent for frozen section and into the cryo unit with liquid nitrogen down to −80 degrees . We were then brought in to remove the rest of the mass. There were some fragments of mass still attached to the nasal wall of the orbit. The frozen section revealed lymphoma, low grade, probably stage I, and since this is radiosensitive and all of the tumor could not be removed without exonerating the orbit, it was elected to close at this point and treat the rest conservatively. The wound was closed after the remaining tumor was infiltrated with Solu-Medrol 125 mg per ml for a total of 2 ml, after which the wound was closed with interrupted 6-0 black nylon suture and Maxitrol ointment. Telfa pad, patch and shield were applied. The patient was sent to the recovery room. There were no complications.
PATHOLOGY REPORT LATER INDICATED: Lymphoma.
ICD-9-CM Codes: ____________, ____________, ____________