THE CODING EDGE® ARCHIVES

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Coding Recommendations - Feature Article 09/15/98
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" operative report.

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Procedure: Extracapsular cataract extraction

Indications for Surgery: The patient is a 67-year-old female who has experienced decreasing vision with blurring and difficulty with close work, particularly reading and sewing. Examination reveals visual acuity of 20/200 in the left eye and 20/100 in the right eye. The lenses reveal senile cataracts, left greater than right. The patient has been medically cleared by her internist, and presents today for elective cataract extraction and IOL implant.
  

Description of Procedure: The patient was taken to the operating room and given intravenous analgesia. A Nadbath and retrobulbar block was administered to the left eye using 2% Xylocaine containing Wydase and epinephrine. The patient was prepped and draped in routine fashion to expose the left eye in a sterile field.

Next a Barraquer lid speculum was inserted. Intraocular pressure was normal to palpation. The globe was in good position for surgery, so no superior rectus bridle suture was needed.

A corneal stab incision was made through the peripheral cornea at 3 o'clock into the anterior chamber with a 15-degree razor blade. The anterior chamber was filled with Healon. A peripheral corneal incision, self-sealing of a shelving nature was made superiorly, using a 2.8-mm. phacoemulsification blade. Following this, an anterior capsulorrhexis, 5.5-mm in diameter, was performed using Stolte forceps and cystotome.

The nucleus was hydrodissected from the cortex by injection of balanced salt solution and then phacoemulsified by dividing it into quadrants and phacoemulsifying each quadrant separately in the posterior chamber. Cortex was aspirated, irrigated, and removed. Posterior capsule was intact. The capsular bag was inflated with Healon.

The incision was gently enlarged from 2.8 to 5.5-mm. The allergan # PC62CNB intraocular lens implant, measuring 22.5 diopters was removed from its protective case, examined and found to be intact. The lens was then irrigated and slid through the incision, and haptics were placed in the capsular bag. The lens was dialed into place so that the haptics were positioned in 9 and 3 o'clock positions. The lens centered well.

Healon was removed by irrigation-aspiration. The incision was examined and found to be watertight and self-sealing. At the end of the procedure, the cornea was clear, the anterior chamber was deep and clear, and the lens was in a good position in the capsular bag. A good result is anticipated. Prior to the procedure the patient had been given 1 gm. of Ancef. At the conclusion of the procedure, Tobradex ophthalmic ointment and a sterile patch and plastic eye shield were applied to the eye. The patient was taken to the outpatient recovery area and will be discharged when fully recovered from anesthesia.


     

Using the above samples, do your own coding and then compare it with our recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.

 

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