# Tear during Cataract surgery



## Ksumansky (May 8, 2009)

I was wondering how to code this complication from a dx stand point. 

After the implant was placed there was some residual cortical material that was being removed there was noted to be a small tear in the posterior capsule with some vitreaous present: therefore a limited anterior vitrectomy was undertaken in a binmanual techniqu through a self sealing paracentesis site............

I was going to use dx 366.16, 871.1, and E870.0  Any thought on this????

Thank you for all your time in advance!


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## mbort (May 8, 2009)

Ksumansky said:


> I was wondering how to code this complication from a dx stand point.
> 
> After the implant was placed there was some residual cortical material that was being removed there was noted to be a small tear in the posterior capsule with some vitreaous present: therefore a limited anterior vitrectomy was undertaken in a binmanual techniqu through a self sealing paracentesis site............
> 
> ...



I would not use the e-code as it pertains to an actual "cut" that would have been caused by the srugeon.  The surgeon is calling it a tear.

Make sense?
Mary, CPC, COSC


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## Ksumansky (May 11, 2009)

so I wouldn't use the e code but I would keep the 871.1? Or did I pick the wrong E code?  Would E878.8 work better in your opinion?

Thank you for your advice.

Kelly


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## mbort (May 11, 2009)

I would check with the surgeon, It sounds to me more like there was some vitreous prolapse from the tear.  

I would not use the 871.1, that is for a laceration (unless you have documentation that actually states "laceration")


The E848.8 could be okay, but before doing that I would check with the surgeon regarding the above.

Hope this helps
Mary, CPC, COSC


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## magnolia1 (May 11, 2009)

If your physician confirms that this "tear" was a result of the procedure, you could use 998.2 with E870.0


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## Jamie Dezenzo (May 12, 2009)

I would agree w/ Karen


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