daniel
True Blue
Hello
Can you help, the provider wants to use 67255. I don't see that. Can you give me your thoughts? On how you would code this.
I scrubbed this note for review, if needed.
Thank You
Pre-op diagnosis: infectious scleritis, right eye
Post op diagnosis: Same
Procedure: scleral debridement, conjunctival cut-down, placement of irrigation tube through eyelid
Anesthesia: Local/MAC
Specimens: None
EBL: < 5 mL
Drain: None
Implant: None
Post-op condition: Good
All risks, benefits, and alternatives of scleral debridement, conjunctival cut-down, placement of irrigation tube through eyelid were discussed with the patient in the office and on the day of surgery, including but not limited to bleeding, infection, failure of the surgery, recurrence, need for additional surgery, scleral thinning leading to ruptured globe, asymmetry, loss of vision, and loss of the eye. The patient expressed understanding and gave signed consent to proceed with the surgery.
The periorbital skin was washed with 10% povidone iodine and the eye was washed with 5% povidone iodine. The patient was given a 2cc subconjunctival injection of 2% lidocaine with epinephrine.
The eye was found to be severely injected with subconjunctival abscesses and scleral melt inferiorly. There was severe scleral thinning nasally with exposure of a calcific plaque anterior to the insertion of the medial rectus. The plaque did not appear to have a biofilm or other surrounding purulence, and beneath the plaque uvea was visible, so the plaque was left in place.
Attention was turned inferiorly, where the conjunctiva was cut down and purulent material was debrided. The lid speculum and drape were then removed from the patient.
Attention was turned superiorly, where 1cc of 2% lidocaine with epinephrine was injected into the peribulbar subconjunctival space in the superior fornix, A 16 gauge needle was passed through the lateral right upper eyelid and a 25 gauge tubing was then passed through the passage. A single knot was tied in the tubing and tucked into the superior fornix, with excess tubing trimmed and the opening of the tubing positioned well in the inferior fornix temporally. We tested the tubing given the knot to make sure that the tubing was patent.
The skin was cleaned and dried and the tubing was taped to the forehead with steri-strips. 1cc of 40mg/mL subconjunctival tobramycin was injected inferiorly.
The patient tolerated the procedure well without complications and was returned to the recovery room.
Can you help, the provider wants to use 67255. I don't see that. Can you give me your thoughts? On how you would code this.
I scrubbed this note for review, if needed.
Thank You
Pre-op diagnosis: infectious scleritis, right eye
Post op diagnosis: Same
Procedure: scleral debridement, conjunctival cut-down, placement of irrigation tube through eyelid
Anesthesia: Local/MAC
Specimens: None
EBL: < 5 mL
Drain: None
Implant: None
Post-op condition: Good
All risks, benefits, and alternatives of scleral debridement, conjunctival cut-down, placement of irrigation tube through eyelid were discussed with the patient in the office and on the day of surgery, including but not limited to bleeding, infection, failure of the surgery, recurrence, need for additional surgery, scleral thinning leading to ruptured globe, asymmetry, loss of vision, and loss of the eye. The patient expressed understanding and gave signed consent to proceed with the surgery.
The periorbital skin was washed with 10% povidone iodine and the eye was washed with 5% povidone iodine. The patient was given a 2cc subconjunctival injection of 2% lidocaine with epinephrine.
The eye was found to be severely injected with subconjunctival abscesses and scleral melt inferiorly. There was severe scleral thinning nasally with exposure of a calcific plaque anterior to the insertion of the medial rectus. The plaque did not appear to have a biofilm or other surrounding purulence, and beneath the plaque uvea was visible, so the plaque was left in place.
Attention was turned inferiorly, where the conjunctiva was cut down and purulent material was debrided. The lid speculum and drape were then removed from the patient.
Attention was turned superiorly, where 1cc of 2% lidocaine with epinephrine was injected into the peribulbar subconjunctival space in the superior fornix, A 16 gauge needle was passed through the lateral right upper eyelid and a 25 gauge tubing was then passed through the passage. A single knot was tied in the tubing and tucked into the superior fornix, with excess tubing trimmed and the opening of the tubing positioned well in the inferior fornix temporally. We tested the tubing given the knot to make sure that the tubing was patent.
The skin was cleaned and dried and the tubing was taped to the forehead with steri-strips. 1cc of 40mg/mL subconjunctival tobramycin was injected inferiorly.
The patient tolerated the procedure well without complications and was returned to the recovery room.