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Loretta Posted Thu 01st of June, 2017 17:27:08 PM
Post-Operative Diagnosis: 1. Palatal Cancer Operations Performed: 1. Left partial maxillectomy 2. Left pedicled buccal fat pad graft 3. Direct Laryngoscopy 4. Alveoloplasty x 1 Quadrant (Upper left) Findings: 1. Circumferential margins submitted for frozen pathology were clear of malignant cells except posterior buccal margin. Additional margin was obtained and submitted for permanent pathology. 2. Left partial maxillectomy submitted for permanent pathology. 3. SpLeft partial maxillectomy Using 0.25% Marcaine with epi, the left maxilla & palate was anesthestized. Bovie electrocautery was used to outline the left palatal lesion with approximately 1.5cm margins. The outline was made over the mesial portion of implant #14, approximately 1cm apically into the maxillary vestibule, across mid-portion of tooth #15 and approximately 2.5cm of the palate. Using oscillating saw, osteotomes and rongeurs the Left partial maxillectomy was removed and submitted for permanent pathology. The maxillary sinus was not violated. The remaining tooth roots from tooth #15 were extracted. The maxillary tuberosity was then removed and an alveoloplasty of the left upper quadrant was completed. Circumferential margins submitted for frozen pathology were clear of malignant cells except posterior buccal margin. Additional margin was obtained and submitted for permanent pathology. Left pedicled buccal fat pad graft Using a subperiosteal approach along the left zygomatic buttress, Left pedicled buccal fat pad graft was harvested using Metzenbaum scissors. The pedicled fat pad was then passively advanced over the left maxillectomy defect site. Using 3-0 vicryl interrupted sutures, the fat pad was secured into place. After the completion of the operation, patients stomach was suctioned with a nasogastric tube and removed. ecimen involved implant #14 & part of tooth #15.
SuperCoder Answered Fri 02nd of June, 2017 01:52:19 AM

Hi Loretta,

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 customerservice@supercoder.com for more information. Thanks !!

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