CODING Corner
Case Study Codes Procedures of Eye
Kim Charland, BA, CCS, ART
Operative Report
Preoperative diagnoses: Horizontal lower eyelid laxity with poor blink function and epiphora; ectropion, both eyes; punctal stenosis.
Procedures: Bilateral lower eyelid lateral canthopexy; bilateral lower eyelid ectropion repair; bilateral lower eyelid one snip punctoplasty and dilation.
Anesthesia: Local monitored anesthesia care (MAC)
Operative technique: The patient was taken to the operating room and placed in the supine position on the operating table. IV sedation was given, and 3 cc of local anesthetic was injected into each lower eyelid at the canthal region and medially below the puncta. The patient was prepped and draped in the usual sterile fashion.
Attention was turned to the left lower lid where a lateral canthotomy and inferior cantholysis were performed. Hemostasis was obtained.
The lateral orbital rim was identified and dissected free of the overlying soft tissue with blunt dissection. A lateral tarsal strip was fashioned by splitting the eyelid vertically to expose the tarsal plate. The lower retractors and conjunctiva were released from the lateral lower border of the tarsal plate. The canthal tendon was excised and a strip of epithelium was removed from the upper border of the tarsal plate (67917).
Double-armed 4-0 Mersilene suture was then brought from posterior to anterior in a horizontal mattress fashion. The arms of this were brought through the periosteum of the lateral orbital rim at the level of the lateral orbital tubercle and left untied.
Then, attention was turned medially to the lacrimal system. A punctal dilator was used to dilate the lower eyelid puncta (68800). It was significantly stenotic. A double-O Bowman probe was placed through the canaliculus, and the lid was retracted anteriorly. A wedge of lower eyelid retractors and conjuctiva was excised, and hemostasis was obtained.
A double-armed 6-0 Vicryl suture was brought through the edges of the conjunctiva posteriorly and then brought through the skin anteriorly 10 mm below the puncta. This was tied on itself and rolled the puncta in against the globe nicely. A punctoplasty was then performed by the one-snip technique (68440).
Attention was then turned back to the lateral canthus where the previously placed Mersilene suture was tied. The lower lid was in good position, both horizontally and vertically on the globe, with minimal distraction.
The skin over the lateral canthal angle was then reconstructed and reformed using multiple interrupted 6-0 mild chromic sutures (21282).
Attention was turned to the right lower eyelid where the same procedures were performed (67917, 68440 and 21282). The patient tolerated the procedure well and was taken from the operating room in good condition.
Code Assignments
Hospital (UB-92 Claim Form)
ICD-9-CM Diagnoses
374.10 Ectropion, unspecified
701.8 Hypertrophic and atrophic conditions of skin
375.20 Epiphora, unspecified cause
ICD-9-CM Procedures
08.44 Repair of entropion/ectro- pion with lid
reconstruction
08.44 Repair of entropion/ectro- pion with lid
reconstruction
08.59 Adjustment of lid position
08.59 Adjustment of lid position
09.72 Repair of punctum
09.72 Repair of punctum
09.41 Probing of lacrimal
punctum
09.41 Probing of lacrimal
punctum
CPT Procedures
67917 Repair of ectropion;
blepharoplasty, extensive
67917 Repair of ectropion;
blepharoplasty, extensive
21282 Lateral canthopexy
21282 Lateral canthopexy
68440 Snip incision of lacrimal punctum
68440 Snip incision of lacrimal punctum
68800 Dilation lacrimal punctum, with or without irrigation,
unilateral or bilateral
Physician (HCFA-1500 Claim Form)
ICD-9-CM Diagnoses
374.10 Ectropion, unspecified
701.8 Hypertrophic and atrophic condition of skin
375.20 Epiphora, unspecified cause
CPT Procedures
67917 Repair of ectropion;
blepharoplasty, extensive
67917- Repair of ectropion; 50-51 blepharoplasty, extensive
68800-51 Dilation lacrimal punctum, with or without irrigation, unilateral or bilateral
Coding Rationale
In this case, the following codes should be assigned twice for the facility component:
* 67917 to reflect an extensive ectropion repair
* 21282 for a lateral canthopexy (Note: Although this code is in the musculoskeletal section of the CPT code book, it is the appropriate code to assign.)
* 68440 to reflect the bilateral snip punctoplasty
In addition to assigning the above codes twice, assign 68800 once (its code description reflects a unilateral or bilateral dilation).
For physician services, bill code 67917 with the bilateral modifier (-50). Do not bill codes 21282 and 68440 separately because they are considered part of 67917, according to the Health Care Financing Administration’s correct coding initiative. Bill 68800 with modifier -51 to indicate the dilation of the lacrimal puncton.
* About the author: Kim Charland, a senior health care consultant with MedLearn, has more than 10 years of experience in health information management. Her expertise includes ICD-9-CM and CPT coding for hospital ambulatory surgery, emergency and anesthesia services as well as physician services.
