luisa Posted Wed 29th of March, 2017 08:47:41 AM
Hello. I captured 40720 & 30462, but quite not sure. Please read below.
1. Secondary Cheiloplasty
2. Secondary cleft nasal reconstruction w/ repair of vestibular stenosis.
4. Removal of cyst x2 in the lip.
1st to the lip where an elliptical incision was made over the lip scar w/ dissection of the cyst which was identified. Cyst was then removed from the central portion of the lip. It was opened and the cheesy material was removed & the base of the cyst once removed was cauterized w/ bipolar cautery.
Next Zplasty type flaps were then cut into the lip where the remaining cutaneous mismatch existed as well as a backcut under the gingival sulcus releasing the tight frenulum, elongating it and closing that from a horizontal to vertical closure w/ 4-0chromic suture. The muscle was then dissected & brought together w/ 4-0 Rapide suture. Flaps were rotated & secured w/ 6-0 nylon suture @ the vermilion cutaneous junction entailing this w/ sharp scissors. The midline incision was closed w/ 6-0nylon.
A Y to V incision was so that the lateral ala could be advanced closer to columella. Further dissection identified a need for support laterally. Therefore, the septum was evaluated and a septal deviation was noted to the left side. That septum was then incised & mucoperichondrial flaps were elevated and the distal inferior portion of the septum & vomer were removed w/ clamps & rongeurs. This opened up the lateral airway significantly. The mucosa was brought together w/ 3-0chromic suture.
Next the rim was debulked of scar. The internal portion of the ala was debulked to scar where the lower lateral should be, but it was minimal & also the ala was retraced; therefore , cartilage and bone graft was then shaped & placed into this space resetting the ala to a much more natural curvature & w/ support. This was secured w/ multiple through - & through 4-0 gut sutures securing the graft into position & readapting the mucosa. The lateral ala was advanced & secured deep w/ a 4-0Monocryle suture, followed by multiple combinations of 6-0nylons & 5-0 gut suture.
SuperCoder Answered Thu 30th of March, 2017 07:34:09 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.