Vol. 17 •Issue 20 • Page 13
Coding Corner
Coding Procedures of the Eye
In the search for the correct code, always be sure to read the descriptions of all the options given in the CPT manual index.
Case Study One
Preoperative and 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. Phacoemulsification of the lens proceeded by sectioning of the lens into quadrants, removing each quadrant. 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 Diagnoses
Preoperative: Nuclear sclerosis 2+ with a 2+ posterior subcapsular cataract, right eye
366.16 Senile nuclear sclerosis
Postoperative: 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 and Rationale
The physician extracted the cataract with the help of a phacoemulsification unit. The intraocular lens (IOL) implant was then inserted, and the wounds of the eye were closed.
To identify the code, check the CPT manual index for the term Phacoemulsification. Listed under this term is Removal with the following indented: Extracapsular Cataract — 66982, 66984. After checking these two codes in the surgery section, you will see that the second one is the correct choice for both the facility and physician. As indicated below, assign modifier RT (right side) 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 or 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 or phacoemulsification)
Case Study Two
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 into 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, which 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 the pathology department. The superior fornix was repaired using running suture of 6-0 plain gut. Bacitracin ointment and eye pad were applied to the eye.
The patient tolerated the procedure well and left the operating room in good condition.
ICD-9-CM Diagnoses
Preoperative: Orbital mass, OD
376.9 Unspecified disorder of orbit
Postoperative: Herniated orbital fat pad, OD
374.34 Blepharochalasis
CPT Code Assignment and Rationale
The surgeon everted the eyelid to get to the herniated fat pad. The incision was made into the conjunctiva to remove the fat pad that measured 0.75 cm in diameter.
To assign the code for the procedure, check the CPT manual index under the term Excision. Next you will look for the term Lesion under which the Conjunctiva — 68110-68130 is listed. Read the descriptions of these codes and you will see that the following is the correct choice. As shown, you also will assign modifier -E3 (upper right, eyelid) to communicate the location of the herniated fat pad removal.
Facility Code Assignment
68110-E3 Excision of lesion, conjunctiva; up to 1 cm; -E3, Upper right, eyelid
Professional Code Assignment
68110 Excision of lesion, conjunctiva; up to 1 cm
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.
