Ophthalmology and Optometry Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: How should I code the removal of an infected scleral buckle? Arizona Subscriber  

  Answer: Let's start with how to choose an appropriate diagnosis code. We're halfway there because your documentation indicates that the buckle was removed because it was infected.

Scleral buckling, a treatment for retinal detachment, uses an explant or an implant to indent, or "buckle" inward, the sclera, closing any holes or tears. These "buckles" are made of materials such as silicone rubber or fascia lata. When an infection causes a buckle to extrude, it can be irritating to the patient. To code for the complication, you have two choices: 996.59 (Complications peculiar to certain specified procedures; due to other implant and internal device, not elsewhere classified) or 996.69 (Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft), depending on the documentation.

The appropriate procedure code is difficult to identify because, as with the ICD9 Codes, there is no specific mention of a scleral buckle in the descriptor of the applicable code. To choose the correct CPT code, you need to know that the scleral buckle is material implanted in the posterior segment of the eye, typically after a retinal tear has been treated by a burn, sealing the choroids to the retina. This description of a buckle will lead you to code 67120 (Removal of implanted material, posterior segment; extraocular).