PREOPERATIVE DIAGNOSES:
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: ____________, ____________, ____________
379.92, 202.81, 16.23
202.81
H04.129, Z96.1, C69.6
To determine the appropriate ICD-9-CM codes for the given preoperative and postoperative diagnoses, we need to match the diagnoses to their corresponding codes in the ICD-9-CM coding system.
1. Left orbitonasal mass:
Search for a code that represents a mass or tumor in the left orbit or nasal area. One possible code is 193.3, which is "Malignant neoplasm of orbital tissue." However, the specific location of the mass may require a more specific code.
2. Dry eye syndrome:
The code for dry eye syndrome is 375.15, which is "Tear film insufficiency, unspecified."
3. Pseudophakia, both eyes:
Pseudophakia refers to the condition of having an intraocular lens implant in one or both eyes. The code for pseudophakia is 366.20, which is "Aphakia, unspecified."
4. Computerized tomography confirmed tumor left orbital, left nasal side:
For a confirmed tumor in the left orbital and nasal side, the appropriate code might be 198.82, which is "Secondary malignant neoplasm of eyelid, including canthus." This code indicates a secondary metastatic tumor while specifying the location as the eyelid.
Postoperative Diagnosis: Low-grade lymphoma, left orbit:
The appropriate code for low-grade lymphoma is 200.8, which is "Other lymphoma."
Thus, the potential ICD-9-CM codes for the given diagnoses are:
1. Left orbitonasal mass: 193.3 (or a more specific code depending on the details)
2. Dry eye syndrome: 375.15
3. Pseudophakia, both eyes: 366.20
4. Computerized tomography confirmed tumor left orbital, left nasal side: 198.82
Postoperative diagnosis: Low-grade lymphoma, left orbit: 200.8