Vol. 14 •Issue 8 • Page 15
Coding Corner
Coding Procedures of the Eye and Ocular Adnexa System
Case Study 1
Preoperative Diagnosis: Nuclear sclerosis 2+ with a 2+ posterior subcapsular cataract, right eye.
Postoperative Diagnosis: Nuclear sclerosis 2+ with a 2+ posterior subcapsular cataract, right eye.
Procedure Performed: Phacoemulsification of cataract with posterior chamber intraocular lens implantation, right eye.
Indication for Procedure: This is a 72-year-old female who complains of gradually decreased vision in her right eye, such that she is having increased difficulty with reading. An ophthalmologic examination revealed vision with correction in the right eye is 20/200. On dilated examination, the right lens has 2+ nuclear sclerosis with a 2+ posterior subcapsular cataract.
The risks and benefits of cataract surgery were explained to the patient. She desires to proceed with cataract surgery on her right eye.
Operative Technique: Local anesthesia was obtained with retrobulbar and modified Van Lint injection using a 50-50 mixture of 4 percent Lidocaine and 0.75 percent Marcaine with Wydase. A Honan balloon was placed for approximately 15 minutes. The patient was positioned, prepped and draped in the usual sterile fashion.
A wire lid speculum was inserted, and the operating microscope was brought into position. A temporal limbal corneal incision was made with a 2.75 mm keratome, and Viscoat was injected into the anterior chamber. Using a cystotome and Utrata forceps, a continuous tear capsulorrhexis was performed. A limbal paracentesis stab incision was made at 6 o’clock with a diamond blade.
Hydrodissection and hydrodelineation of the lens was accomplished with balanced salt solution via cannular injection. Phaco-emulsification of the lens proceeded as the lens was sectioned into quadrants with each quadrant removed. Residual lens cortex was removed with irrigation and aspiration.
The posterior capsule was polished with an irrigating Graether collar button. Viscoat was injected into the capsular bag, and the cataract incision was opened with the keratome. Using lens-folding forceps, an Alcon, Model MA60VM, 6.0 mm optic, 21.5 diopter posterior chamber intraocular lens was inserted into the capsular bag. A sinskey hook was used to facilitate rotation and centration of the lens.
Residual anterior chamber Viscoat was removed with irrigation and aspiration. Balanced salt solution was injected into the anterior chamber, and the wound was observed to be water tight. Subconjunctival Celestone and Cefazolin were injected. Topical Iopidine solution and Maxitrol ophthalmic ointment were instilled. Dressing included eye pad and Fox shield.
The patient tolerated the procedure well without complications.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Nuclear sclerosis 2+ with a 2+ posterior subcapsular cataract, right eye
366.16 Senile nuclear sclerosis
366.14 Posterior subcapsular polar senile cataract
Postoperative Diagnosis: Nuclear sclerosis 2+ with a 2+ posterior subcapsular cataract, right eye
366.16 Senile nuclear sclerosis
366.14 Posterior subcapsular polar senile cataract
CPT Code Assignment
With the use of phacoemulsification unit, the cataract was extracted. The physician then inserted the intraocular lens (IOL) implant and closed the wounds of the eye.
When you look in the CPT manual index under the term Phacoemulsification, you will see the term Removal below it. Indented under Removal Extracapsular Cataract, 66982, 66984. When you check the code descriptions, you will see that the correct code is 66984. For the facility code assignment you would also assign modifier -RT, right side of body, to communicate that the right eye was the operative site.
Facility Code Assignment
66984-RT Extracapsular cataract removal with insertion of intraocular lens prosthesis (one-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration of phacoemulsification)
Professional Code Assignment
66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration of phacoemulsification)
Case Study 2
Preoperative Diagnosis: Orbital mass, OD
Postoperative Diagnosis: Herniated orbital fat pad, OD
Procedure Performed: Excision of mass and repair, right superior orbit
Anesthesia: Local
Operative Technique: After Proparacaine was instilled in the eye, it was prepped and draped in the usual sterile manner and 2 percent Lidocaine with 1:200,000 epinephrine was injected into the superior aspect of the right orbit. A corneal protective shield was placed in the eye. The eye was placed in down-gaze.
The upper lid was everted and the fornix examined. The herniating mass was viewed and measured at 0.75 cm in diameter. Westcott scissors were used to incise the fornicele conjunctiva. The herniating mass was then clamped, excised and cauterized. It appeared to contain mostly fat tissue, which was sent to pathology.
The superior fornix was repaired using running suture of 6-0 plain gut. Bacitracin ointment was applied to the eye followed by an eye pad. The patient tolerated the procedure well and left the operating room in good condition.
ICD-9-CM Code Assignment
Preoperative Diagnosis: Orbital mass, OD
376.9 Unspecified disorder or orbit
Postoperative Diagnosis: Herniated orbital fat pad, OD
374.34 Blepharochalasis
CPT Code Assignment
The surgeon had to evert the eyelid to get to the herniated fat pad. The incision was made into the conjunctiva to remove the fat pad, which measured 0.75 cm in diameter.
To assign the code for this procedure, check the CPT coding manual index for the terms Excision, then Lesion. Indented under the second term, you will find Conjunctiva. Two options are given under that term: one for over 1 cm 68115 and the other for with Adjacent Sclera 68130. After checking the code descriptions, you will see that code 68115 is the correct code. Modifier E3 (upper right, eyelid) should be appended to the facility code to communicate from which eyelid the physician removed the herniated fat pad.
Facility Code Assignment
68110 Excision of lesion, conjunctiva; up to 1 cm
Professional Code Assignment
68110 Excision of lesion, conjunctiva; up to 1 cm
Susan Howe is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.
