# Vitrectomy coding help



## vmounce (Jun 28, 2011)

Can someone help me out with op note below?  My thoughts are 67005 LT 360.00 379.92. 

VICKIE MOUNCE

Doctor says 67036 & 67028-but I show 67028 is bundled.  I appreciate any info.  See below:

 PREOPERATIVE DIAGNOSES:  
Left eye endophthalmitis. 
Left eye anterior chamber consolidated mass. 

POSTOPERATIVE DIAGNOSES:  
Left eye endophthalmitis. 
Left eye anterior chamber consolidated mass. 

PROCEDURE:  
25-gauge pars plana vitrectomy. 
Intravitreal antibiotics. 

INDICATIONS:  The patient developed endophthalmitis two weeks following primary vitrectomy surgery.  

BRIEF HISTORY:  Patient underwent pars plana vitrectomy surgery with membrane peel, which was an uneventful case two weeks prior to this surgery.  The patient was seen in the clinic on the day of surgery and she was noted to have a consolidated mass in the anterior chamber with 3+ cell and a disorganized posterior chamber on B-scan consistent with presumed bacterial endophthalmitis secondary to previous surgery.  

By history, the patient had been able to get most of her drops and her son had come by and looked at her but she had been rubbing her eye with Kleenex constantly after surgery.  The patient had noted some decreased vision and pain.  She also noted that her pupil was not black and she presented to the clinic for evaluation.  The risks, benefits, and alternatives of the surgery were explained to the patient.  She had a very guarded and poor prognosis due to the severity of the endophthalmitis.  However, she needed antibiotics to clear the infection in an attempt to salvage her vision and to salvage her eye.

OPERATIVE PROCEDURE:  The patient was identified in the preoperative holding area and her left eye was identified as the operative eye.  She was taken to the operating suite at Cumberland Valley Surgical Center.  She was monitored by anesthesia throughout the case.  

The patient was then prepped and draped in the usual sterile ophthalmic fashion.  An eyelid speculum was placed in the left eye and a standard peribulbar block of 7 cc of a 50:50 mix of 1% lidocaine and 0.75% Bupivacaine was injected with a blunt-tipped cannula for akinesia and anesthesia.

A standard 25-gauge trocar infusion set was placed in the anterior chamber at the limbus.  A vitrector was inserted before irrigation was run and it was used to aspirate and cut the anterior chamber mass, which was a consolidated fibrin infection.  The sample was collected in a 3 cc syringe and sent for Gram stain and culture.

The 25-gauge instruments were removed from the eye and a 25-gauge infusion and working sclerotomy were placed 3.5 mm from the limbus and measured by calipers.  The infusion line was then able to be visualized in the eye but it did aspirate through to the extrusion line and therefore showing that it was in the intravitreal cavity.  

The vitrector was inserted and used to perform a core vitrectomy behind the lens.  There was no BIOM visualization and the lens was somewhat cloudy but all of the white debris and infection that was behind the lens was aspirated.  

Because there was no view, a full pars plana with BIOM viewing system could not be performed but an anterior vitrectomy was performed.  

The sclerotomy ports were removed from the eye and they were sutured using X-fashion 6-0 plain gut suture in both areas until they were noted to be watertight.  The intraocular pressure was lowered with an anterior chamber paracentesis and 1 mg of Vancomycin and 2.25 mg of Ceftazidime was injected into the vitreous cavity.  Approximately 0.3 cc or 0.3 mg of Vancomycin was injected into the anterior chamber as well.  The same concentration of Vancomycin was injected subconjunctivally and the intraocular pressure was left at approximately 15 by digital palpation.  The eyelid speculum was removed from the eye.  The eye was pressure patched with Erythromycin ointment to be left in place overnight.  The patient was transferred from the operating room to the recovery room in stable condition.  She was watched and then discharged home with her son on the same day.  The patient was given instructions to leave the patch on overnight and to follow up in the eye clinic for postoperative day #1 check.


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## dkeown (Jun 29, 2011)

After review of the current Coding Companion for Ophthalmology I would agree that 360.00 379.92 would be appropriate, but not the 67036, 67028 or 67005.  67005 describes an "Open Sky Technique" and the physician describes the mechanical removal of the vitreous - 67010 LT would be more in line with the procedure note.

Hope this helps!
David Keown, CPC, OCS


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## vmounce (Jun 29, 2011)

I appreciate the info.

Thanks,
vickie


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