Assign the appropriate ICD-9-CM, ICD-10-CM/PCS, and CPT diagnosis and procedure codes for hospital ambulatory surgery.
PREOPERATIVE DIAGNOSIS: Bilateral upper eyelid lateral levator aponeurotic ptosis due to senescence, bilateral upper eyelid functional dermatochalasis.
POSTOPERATIVE DIAGNOSIS: Bilateral upper eyelid lateral levator aponeurotic ptosis due to senescence, bilateral upper eyelid functional dermatochalasis.
OPERATIONS PERFORMED: Bilateral blepharoptosis repair by external levator resection, bilateral blepharoplasty.
ANESTHESIA GIVEN: Local monitored anesthesia care.
ESTIMATED BLOOD LOSS: Less than 5 cc.
INDICATIONS FOR PROCEDURE: The patient is a 61-year-old female who presents with a complaint of constricted vision in both eyes secondary to drooping eyelids restricting reading and driving. On previous office exam, the patient was noted to have a severe ptosis with absence of lid crease and a poor levator function on both sides in addition to excess and redundant eyelid skin with edema. After discussing these findings with the patient and obtaining visual fields, taped and untaped, and confirming that a significant functional superior field defect was present in both eyes and obtaining clinical photographs, the patient agreed to have the above-named procedure performed after explanation of the risks and benefits.
DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operative area and was prepped and draped in the usual sterile fashion following adequate anesthesia obtained utilizing a mixture of 50/50 2% Xylocaine with epinephrine and 0.75% Marcaine. Prior to this, the eyelid region to be resected was identified and marked with a marking pen. With the patient in the supine position, a #15 blade was then used to cut through skin along the fusiform section of the eyelid tissue to be removed in the right eye.
Blepharoplasty was performed. The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.
The previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.
The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. A similar procedure was performed exposing herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver.
Next, blepharoptosis repair was performed. Good hemostasis was obtained utilizing the fine-point Bovie electrocautery instrument. Addressing the superior one-half of the fusiform section, a plane was dissected down to pre-aponeurotic fat and the levator aponeurosis was identified. It was noted to have fatty infiltration and significant atrophy. At this point, the tarsus was identified by excising the fusiform section of orbicularis previously marked. A dissection plane through the orbicularis at the superior aspect of the tarsus was performed and this was advanced to the inferior margin of the tarsus. This plane was dissected laterally and temporally and nasally. A good hemostasis was again obtained throughout the procedure. At this point, double-armed 6-0 silk sutures on a TG-140 needle were then utilized to pass through the superior aspect of the levator aponeurosis and then this was passed through the tarsus. The fellow sutures were passed laterally and nasally to the centrally passed suture. At this point, the sutures were tightened and the desired level of lid elevation and contour were obtained. These sutures were then tied permanently and cut.
The lateral aspect of the upper eyelid incision was then closed utilizing interrupted 6-0 Prolene sutures by incorporating skin, orbicularis, and levator aponeurosis on the inferior portion and then skin on the superior portion of this interrupted suture. A simple running suture was then passed through skin, utilizing a 6-0 Prolene suture.
The same procedure was performed for the patient on the fellow eye; levator resection and removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis was obtained on the upper lid areas.
At the end of the operation, the patient’s vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, and no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally. It should be noted that the patient received 12 mg of Decadron intravenously on-call in the OR as well as 1 gram of Kefzol intravenously in the OR on-call.
The patient tolerated the procedure well without complications and returned to the recovery area in stable condition.
Code this scenario with ICD-9-CM, CPT and ICD-10-CM and -PCS codes.