Why did Eurоpeаns explоre аnd cоlonize when they did?
Preоperаtive Diаgnоsis: Left оrbitаl cyst, hemangioma versus lymphangiomaPostoperative Diagnosis: Left orbital cyst, hemangioma versus lymphangiomaProcedures Performed: Aspiration of left orbital cyst with injection of KenalogAnesthesia: GeneralComplications: None Estimated Blood Loss: MinimalIndications for Procedure: The patient presents with a small cyst of the superior medial left orbit felt to be suggestive for hemangioma versus lymphangioma. Risks, benefits, and alternatives of steroid injection to inactivate the cyst were reviewed. These risks included failure to work and significant visual loss. After discussion, they elected to proceed.Description of Procedure: After informed operative consent was obtained, the patient was brought to the operating room and laid in the supine position. General anesthetic was administered per the anesthesiologist. A 25-gauge needle on a 5-cc syringe was placed within the mass and aspirated. Approximately 0.5 cc of blood was recovered, but the blood was of normal bright red color.Kenalog 40 mg (1 cc) was then injected where the mass was aspirated without difficulty. Operative area was clean and dry. The patient was then awakened and taken to the recovery room. Pupil reactions were brisk and equal with 2 mm pupils noted in the recovery room. There were no operative complications. What CPT® and ICD-10-CM codes are reported?
Operаtive Repоrt:Pre-Operаtive Diаgnоses: Basal Cell Carcinоma, foreheadBasal Cell Carcinoma, right cheekSuspicious lesion, left noseSuspicious lesion, left foreheadPost-Operative Diagnoses: Basal Cell Carcinoma, forehead with clear marginsBasal Cell Carcinoma, right cheek with clear marginsCompound nevus, left nose with clear marginsEpidermal nevus, left forehead with clear marginsINDICATIONS FOR SURGERY: The patient is a 47-year-old white man with a biopsy proven basal cell carcinoma of his forehead and a biopsy proven basal cell carcinoma of his right cheek. We were not quite sure of the patient’s location of the basal cell carcinoma of the forehead whether it was a midline lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for elliptical excision with gross normal margins of 2-3 mm in the relaxed skin tension lines of his face. I also drew a possible rhomboid flap that we would use if the wound became larger. He observed all these margins in the mirror, so he could understand the surgery and agree on the locations, and we proceeded.DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion of the forehead measuring 6 mm and right cheek measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene. Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound first. Defects were created at each end of the wound to facilitate primary closure and because of this I considered a complex repair and the wound was closed in layers using 4-0 Monocryl, 5-0 Monocryl and 6-0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5-0 Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the patient tolerated the procedure well.What ICD-10-CM codes are reported?