Operative Report Entropion Explained for Students (Easy Guide)

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Original Question

Operative Report, Entropion and Ectropion Repair Use HCPCS modifiers when reporting the services for this patient. LOCATION: Outpatient, Hospital PATIENT: Robert Vobr ATTENDING PHYSICIAN: Rita Wimer, MD PREOPERATIVE DIAGNOSIS: 1. Upper lid entropion, both eyes; lower lid ectropion, both eyes 2. Graves’ disease 3. Status post chemical decompression for Graves’ disease 4. Chronic exposure, keratitis secondary to diagnoses 1, 2, and 3 5. Chronic conjunctivitis secondary to diagnoses 1, 2, 3, and 4 POSTOPERATIVE DIAGNOSIS: 1. Upper lid entropion, both eyes; lower lid ectropion, both eyes 2. Graves’ disease 3. Status post chemical decompression for Graves’ disease 4. Chronic exposure, keratitis secondary to diagnoses 1, 2, and 3 5. Chronic conjunctivitis secondary to diagnoses 1, 2, 3, and 4 OPERATIONS PERFORMED: 1. Upper lid entropion repair, both eyes 2. Lower lid ectropion repair, both eyes ANESTHESIA: MAC INDICATION: The patient has had progressive increase of upper lid entropion and lower lid ectropion, ptosis, and a number of other problems secondary to eye disease related to thyroid disease. The excess tissue is now interfering with his vision. DESCRIPTION OF PROCEDURE: After the patient was placed on the operating room table, the skin to be resected on the upper lid was marked out with a blue sterile marking pen, as was the lower lid. There was a fishtail superiorly and lateral oblique inferiorly. This was infiltrated with Xylocaine 2%, 0.75% Marcaine, and bicarbonate. It was on a 25-gauge needle, and a total of 40 cc was used throughout the procedure. The 15 Bard-Parker blade then dissected the skin to be resected superiorly on the upper lids. This was freehand dissected, and a 2-mm (millimeter) strip of orbicularis was removed. The lateral, central, and medial fat pads were isolated, clamped, cut, and cauterized on the upper lids. The wound was reapproximated without supratarsal fixation using 6-0 nylon black suture to create a 2-mm ectropion of the upper lids. The lower lids were cut out with a 15 Bard-Parker blade through the marked incision. The fat pads centrally, medially, and laterally were identified, clamped, cut, cauterized, and allowed to retract. The amount of skin to be resected inferiorly was determined by the up-eye/open-mouth position, and this was mainly a lateral resection. The wounds were then closed with 6-0 nylon sutures. Maxitrol ointment and Telfa strips were laid on all four lids and half patches so the eyes remained open. There were no complications. SERVICE CODE(S): ______________________________________ ICD-10-CM DX CODE(S): ______________________________

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