Hi list,
I am new to coding Optho and am needing some guidance. Would you code 67040 & 66821? TIA
Melissa Bedford,CCS,CPC
Pre-operative diagnosis: posterior capsular opacification thick, proliferative diabetic retinopathy
Post-operative diagnosis: same
Procedure/description: posterior capsulotomy, vitrectomy
Operative findings: same
Specimens: none
Fluids/Blood: per team
Estimated Blood Loss: Minimal
Drains/Packs: none
Patient's condition: stable
12/2/2014
8:05 AM
SURGEON:
ASSISTANT SURGEON:
None.
PREOPERATIVE DIAGNOSIS(ES):
Posterior capsular opacification, thick, and proliferative
diabetic retinopathy.
POSTOPERATIVE DIAGNOSIS(ES):
Posterior capsular opacification, thick, and proliferative
diabetic retinopathy.
PROCEDURE(S)/OPERATION(S) PERFORMED:
Posterior capsulotomy, vitrectomy.
OPERATIVE FINDINGS:
Posterior capsular opacification, thick, and proliferative
diabetic retinopathy.
SPECIMENS:
None.
FLUIDS:
Per team.
ESTIMATED BLOOD LOSS:
Minimal.
DRAINS:
None.
CONDITION AT END:
Stable.
COMPLICATIONS:
None.
PREOPERATIVE HISTORY:
Mrs. is a 70-year-old Hispanic female with longstanding
history of vision loss in her left eye. After long discussion of
possible risk, possible benefits of the procedure, the patient
wished to go ahead with the procedure. Risks that were discussed
were vision loss, partial or total, need for multiple procedures,
infection, pain. Despite this, she wished to go ahead.
SUMMARY:
The patient was brought to the OR, prepped and draped in the
usual fashion. Lid speculum was placed in the left eye. Three-
port pars plana vitrectomy system was done. Initially, the
inferior temporal trocar was placed at 4:30. Infusion was
inserted under direct viewing, seen to be in the vitreous cavity.
Superior temporal superior nasal trocars were placed at 2 and 10
o'clock. Light pipe, 23-gauge vitrector and biome were used to
make a core vitrectomy. This was done prior. However, there was
a very thick posterior capsule opacification. This was removed
with the vitrector, and delicately as it was very thick and stuck
onto the lens, the endolaser was then placed posteriorly and
under scleral depression. The patient tolerated the procedure
well. There were no complications.
I am new to coding Optho and am needing some guidance. Would you code 67040 & 66821? TIA
Melissa Bedford,CCS,CPC
Pre-operative diagnosis: posterior capsular opacification thick, proliferative diabetic retinopathy
Post-operative diagnosis: same
Procedure/description: posterior capsulotomy, vitrectomy
Operative findings: same
Specimens: none
Fluids/Blood: per team
Estimated Blood Loss: Minimal
Drains/Packs: none
Patient's condition: stable
12/2/2014
8:05 AM
SURGEON:
ASSISTANT SURGEON:
None.
PREOPERATIVE DIAGNOSIS(ES):
Posterior capsular opacification, thick, and proliferative
diabetic retinopathy.
POSTOPERATIVE DIAGNOSIS(ES):
Posterior capsular opacification, thick, and proliferative
diabetic retinopathy.
PROCEDURE(S)/OPERATION(S) PERFORMED:
Posterior capsulotomy, vitrectomy.
OPERATIVE FINDINGS:
Posterior capsular opacification, thick, and proliferative
diabetic retinopathy.
SPECIMENS:
None.
FLUIDS:
Per team.
ESTIMATED BLOOD LOSS:
Minimal.
DRAINS:
None.
CONDITION AT END:
Stable.
COMPLICATIONS:
None.
PREOPERATIVE HISTORY:
Mrs. is a 70-year-old Hispanic female with longstanding
history of vision loss in her left eye. After long discussion of
possible risk, possible benefits of the procedure, the patient
wished to go ahead with the procedure. Risks that were discussed
were vision loss, partial or total, need for multiple procedures,
infection, pain. Despite this, she wished to go ahead.
SUMMARY:
The patient was brought to the OR, prepped and draped in the
usual fashion. Lid speculum was placed in the left eye. Three-
port pars plana vitrectomy system was done. Initially, the
inferior temporal trocar was placed at 4:30. Infusion was
inserted under direct viewing, seen to be in the vitreous cavity.
Superior temporal superior nasal trocars were placed at 2 and 10
o'clock. Light pipe, 23-gauge vitrector and biome were used to
make a core vitrectomy. This was done prior. However, there was
a very thick posterior capsule opacification. This was removed
with the vitrector, and delicately as it was very thick and stuck
onto the lens, the endolaser was then placed posteriorly and
under scleral depression. The patient tolerated the procedure
well. There were no complications.