Lip laceration requiring plastic surgery repair

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Documentation Dissection Indication: 4-year-old with complex lip laceration requiring plastic surgery repair. Plastics requested we provide sedation in support of their procedure. Procedure: 21:55 Moderate sedation: I have discussed the moderate sedation procedure with the patient including alternative therapy benefits, and the following risks: pain at site, respiratory arrest. The patient and/or representative understands and agrees to the procedure. Pre-procedure assessment: Healthy, no underlying organic disease. Airway Assessment: Able to hyperextend neck, able to maintain airway, can open mouth without difficulty. Monitoring during procedure: cardiac monitor, continuous pulse oximetry, Medications employed: Versed 2 mg IV. I remained at the patient's bedside during the procedure. Patient remained sedated but was able to follow commands. Total intraservice time was 17 minutes. Post-procedure assessment: The patient is mildly sedated. Respiratory status: Even and unlabored, a reversal agent was not used. Final Diagnosis: Laceration to right upper lip without foreign body What are the CPT® and ICD-10-CM codes reported?

Reference no: EM133795759

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