44. OPERATIVE REPORT
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 anesthesia.
INDICATIONS: 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 medical 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 orangish-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 and was 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 1, and since this is radiosensitive and that all of
the tumor could not be removed without exenterating 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.
CPT CODE(S):
this from a medical book....were the question tho....but I still don't know what the answer is
The CPT code for this procedure would be 67820 - Excision of lesion of eyelid (except chalazion), with excision of lesion of adjacent tissue, when performed.
Based on the information provided, the CPT code for this procedure would be determined by the specific documentation in the operative report regarding the type and extent of the procedure performed. The most appropriate CPT code for this procedure would likely be:
CPT code 67311 - Orbitotomy for excision or biopsy of intraconal tumor
This code is used for an anterior orbitotomy with debulking and biopsy, which seems to align with the description provided in the operative report. However, it is important to note that the CPT code ultimately chosen should be based on the specific details outlined in the full operative report and any applicable coding guidelines and documentation requirements. It is recommended to consult with a medical coding professional or reference the complete operative report to ensure accurate coding.