simam
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Dear all,
below example shows the right code only one 67107 but dont code for C3F8 Gas . is this gas bundled with prim code or some other reason thanks
Anesthesia: Laryngeal mask anesthesia.
Preoperative diagnosis: Retinal detachment, right eye.
Postoperative diagnosis: Retinal detachment, right eye.
Procedure: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the
right eye.
Procedure: After the patient had received adequate laryngeal mask anesthesia, he was
prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye.
A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors.
Each of the intramuscular quadrants was dissected using Aebli scissors. The muscles were
isolated using a Gass muscle hook with an 0 silk suture attached to it. The patient had an
inspection of the intramuscular quadrants and there was no evidence of any anomalous
vortex veins or thin sclera. The patient had an examination of the retina using an indirect
ophthalmoscope and he was noted to have 3 tears in the temporal and inferotemporal
quadrant and 2 tears in the superior temporal quadrant. These were treated with
cryoretinopexy. Most posterior edge of each of the tears was marked with a scleral marker
followed by a surgical marking pen. The patient had 5-0 nylon sutures placed in each
of the 4 intramuscular quadrants. The 2 temporal sutures were placed with the anterior
bite at about the muscle insertion, the posterior bite 9 mm posterior to this. In the nasal
quadrants the anterior bite was 3 mm posterior to the muscle insertion and the posterior
bite was 3 mm posterior to this. A 240 band was placed 360 degrees around the eye and
a 277 element from approximately the 5-1 o’clock position. The patient had another
examination of the retina and was noted to have a moderate amount of subretinal fluid, so
a drainage sclerotomy site was created at approximately the 9:30 o’clock position incising
the sclera until the choroid was visible. The choroid was then punctured with a #30-gauge
needle. A moderate amount of subretinal fluid was drained from the subretinal space. The
eye became relatively soft and 0.35 ml of C3FS gas was injected into the vitreous cavity 3.5
mm posterior to the limbus. The superior temporal and inferior temporal and superior
nasal sutures were tied down over the scleral buckle. The 240 band was tightened up and
excessive scleral buckling material was removed from the eye. The inferior nasal suture
was tied down over the scleral buckle and all knots were rotated posteriorly. The eye was
reexamined. The optic nerve was noted to be nicely perfused. The tears were supported
on the scleral buckle. There was a small amount of residual subretinal fluid. The patient
received posterior sub-Tenon Marcaine for postoperative pain control. The 0 silk sutures
were removed from the eye. The conjunctiva was closed with #6-0 plain gut suture. The
patient received subconjunctival Ancef and dexamethasone. The patient was patched with
atropine and Maxitrol ointment.
2.
3.
4.
1. The postoperative diagnosis is
used for coding.
2. Exam reveals the location of
the tears.
3. Cryoretinopexy is the use of
intense cold to close the tear
in the retina.
4. A sclerotomy is performed to
drain subretinal fluid.
5. Sclera buckling is performed.
1.
5.
15.2 2014 Medical Coding Training: CPC Practical Application Workbook—Instructor CPT® copyright 2013 American Medical Association. All rights reserved.
Eye and Ocular Adnexa, Auditory Systems Chapter 15
The patient tolerated the procedure well and returned to the postoperative recovery room.
What are the CPT® and ICD-9-CM codes reported?
CPT® code: 67107-RT
below example shows the right code only one 67107 but dont code for C3F8 Gas . is this gas bundled with prim code or some other reason thanks
Anesthesia: Laryngeal mask anesthesia.
Preoperative diagnosis: Retinal detachment, right eye.
Postoperative diagnosis: Retinal detachment, right eye.
Procedure: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the
right eye.
Procedure: After the patient had received adequate laryngeal mask anesthesia, he was
prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye.
A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors.
Each of the intramuscular quadrants was dissected using Aebli scissors. The muscles were
isolated using a Gass muscle hook with an 0 silk suture attached to it. The patient had an
inspection of the intramuscular quadrants and there was no evidence of any anomalous
vortex veins or thin sclera. The patient had an examination of the retina using an indirect
ophthalmoscope and he was noted to have 3 tears in the temporal and inferotemporal
quadrant and 2 tears in the superior temporal quadrant. These were treated with
cryoretinopexy. Most posterior edge of each of the tears was marked with a scleral marker
followed by a surgical marking pen. The patient had 5-0 nylon sutures placed in each
of the 4 intramuscular quadrants. The 2 temporal sutures were placed with the anterior
bite at about the muscle insertion, the posterior bite 9 mm posterior to this. In the nasal
quadrants the anterior bite was 3 mm posterior to the muscle insertion and the posterior
bite was 3 mm posterior to this. A 240 band was placed 360 degrees around the eye and
a 277 element from approximately the 5-1 o’clock position. The patient had another
examination of the retina and was noted to have a moderate amount of subretinal fluid, so
a drainage sclerotomy site was created at approximately the 9:30 o’clock position incising
the sclera until the choroid was visible. The choroid was then punctured with a #30-gauge
needle. A moderate amount of subretinal fluid was drained from the subretinal space. The
eye became relatively soft and 0.35 ml of C3FS gas was injected into the vitreous cavity 3.5
mm posterior to the limbus. The superior temporal and inferior temporal and superior
nasal sutures were tied down over the scleral buckle. The 240 band was tightened up and
excessive scleral buckling material was removed from the eye. The inferior nasal suture
was tied down over the scleral buckle and all knots were rotated posteriorly. The eye was
reexamined. The optic nerve was noted to be nicely perfused. The tears were supported
on the scleral buckle. There was a small amount of residual subretinal fluid. The patient
received posterior sub-Tenon Marcaine for postoperative pain control. The 0 silk sutures
were removed from the eye. The conjunctiva was closed with #6-0 plain gut suture. The
patient received subconjunctival Ancef and dexamethasone. The patient was patched with
atropine and Maxitrol ointment.
2.
3.
4.
1. The postoperative diagnosis is
used for coding.
2. Exam reveals the location of
the tears.
3. Cryoretinopexy is the use of
intense cold to close the tear
in the retina.
4. A sclerotomy is performed to
drain subretinal fluid.
5. Sclera buckling is performed.
1.
5.
15.2 2014 Medical Coding Training: CPC Practical Application Workbook—Instructor CPT® copyright 2013 American Medical Association. All rights reserved.
Eye and Ocular Adnexa, Auditory Systems Chapter 15
The patient tolerated the procedure well and returned to the postoperative recovery room.
What are the CPT® and ICD-9-CM codes reported?
CPT® code: 67107-RT