# Retinal detachment code Help please



## msaski69 (Mar 30, 2009)

This woman who had loss of vision found to be secondary to a retained lens fragment that dropped during cataract surgery. Now come back to have:

1.  Pars plana vitrectomy.
2.  Pars plana lensectomy.
3.  Membrane peel with repair of tractional retinal detachment. 4.  Intravitreal Kenalog injection, 4 mg.

Under monitored anesthesia care, a retrobulbar block of 0.75% Marcaine mixed with 2% lidocaine was given in a 50/50 mixture.  A total of 6 cc were given in the retrobulbar space without complications.  The right eye was prepped and draped in a sterile manner typical for intraocular procedure.  A conjunctival peritomy was made from the 1 o'clock to the 5 o'clock position, from the 9 o'clock to 11 o'clock position, and then infratemporally at 3 mm from the surgical limbus.  A 7-0 Vicryl was placed in a mattress style fashion in the bed of the mattress suture.  An MVR blade was used to make a sclerotomy site.  The infusion line was sutured in place with preplaced 7-0 Vicryl and turned on without complication.  The MVR blade was used to make sclerotomies at the 2 o'clock and 10 o'clock positions, again at 3 mm from the surgical limbus.  A core vitrectomy was then performed.  The entire lens was noted to be in the vitreous substance.  Vitrector was used to free the lens from the vitreous.  The fragmatome was used to remove the large majority of the nuclear fragments.  The vitreous cutter was then used to remove the residual nuclear fragments.  The vitreous was then shaved to the vitreous base as much as possible.  The area of tractional retinal detachment was relieved from its anterior-posterior connections, as well as an area of traction along the superior arcade and along the inferotemporal arcade.  As the major goals of the surgery were accomplished with complete removal of the nucleus and cortical fragments, Kenalog was then placed in the eye to combat postoperative inflammation.  A 7-0 Vicryl was used to then close the sclerotomies, and the infusion line was removed and closed with preplaced 7-0 Vicryl.  The conjunctiva was reapproximated with 7- 0 Vicryl.  Subconjunctival injections of dexamethasone and Kefzol were given.  Bacitracin ointment and atropine were placed, and the eye was patched and shielded.  The patient will follow up the following day for postoperative care. 

I coded with 67113 but I'm not sure if the doctor actually do the repair. Please help me with this case. Thank you so much!


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