Hello, I'm new to coding for eye surgery - I code for an ASC, I need help with the following operative report, please and thank you!
Post op DX:
Severe corneal scar, iris adhesions and scaring.
4+ to 5+ brunescent cataractous lens.
Indications: Presented in the office with a severe corneal scar causing the inferior cornea to be opaque on the right eye and a light perception cataract, a brunescent 5+ brown cataract, this was form a congenital lesion and/or inficetion when he was a newborn. He was planned for removal of scar, removal of adhesions to iris to the cornea and extracapsular cataract extraction with trypan blue and iris retractors.
OPERATIVE PROCEDURE: He was taken to the operating room where he was preppped and draped in the usual manner for anterior segment surgery of the right eye. The upper lid was elevated with Steri-Strips. Lashes were taped with sterile tape. Lid speculum was inserted. A 1 mm paracentesis was made with universal diamond blade. Exam under anesthesia was made. Lidocaine ws instilled into the anterior chamber and the iris was swept with viscoelastic on a small cannula, but it could not be totally removed from the posterir cornea. Another paracentesis was made 180 degrees away from the first and againa sweeping motion was made to dissect the iris adhesions away from the posterior cornea, but it could not be completely disengaged. Therefore, a 3mm incision was made with a diamond blade making a trap-door self-sealing incision. Then, microscissors were used to cut the adhesions of the iris to the posterior cornea. The opacification of the inferior cornea was so severe that it was felt to be unsafe at the present time to perform an extracapsular cataract extraction due to poor visibility. Also, the cornea had a slight haze to it making definition of the anterior capsule difficult to qualify; therefore, the incisions were closed with hydration. Viscoelastic was removed. Topical antiiotic........
I have for DX: 371.00 364.70 and 366.16
I'm not sure how to code the aborted cataract surgery? 66984-52?
UPDATE:
I am going to bill it like this 66984-52-RT. If anyone has any suggestions or comments I would appreciate it. (I can turn in a corrected claim)
66600 is included......right?
I would appreciate any help I could get with this operative report! I really want to do it right. Thank you!
Hope
ASC Coder in Omaha NE - Go Huskers!
Post op DX:
Severe corneal scar, iris adhesions and scaring.
4+ to 5+ brunescent cataractous lens.
Indications: Presented in the office with a severe corneal scar causing the inferior cornea to be opaque on the right eye and a light perception cataract, a brunescent 5+ brown cataract, this was form a congenital lesion and/or inficetion when he was a newborn. He was planned for removal of scar, removal of adhesions to iris to the cornea and extracapsular cataract extraction with trypan blue and iris retractors.
OPERATIVE PROCEDURE: He was taken to the operating room where he was preppped and draped in the usual manner for anterior segment surgery of the right eye. The upper lid was elevated with Steri-Strips. Lashes were taped with sterile tape. Lid speculum was inserted. A 1 mm paracentesis was made with universal diamond blade. Exam under anesthesia was made. Lidocaine ws instilled into the anterior chamber and the iris was swept with viscoelastic on a small cannula, but it could not be totally removed from the posterir cornea. Another paracentesis was made 180 degrees away from the first and againa sweeping motion was made to dissect the iris adhesions away from the posterior cornea, but it could not be completely disengaged. Therefore, a 3mm incision was made with a diamond blade making a trap-door self-sealing incision. Then, microscissors were used to cut the adhesions of the iris to the posterior cornea. The opacification of the inferior cornea was so severe that it was felt to be unsafe at the present time to perform an extracapsular cataract extraction due to poor visibility. Also, the cornea had a slight haze to it making definition of the anterior capsule difficult to qualify; therefore, the incisions were closed with hydration. Viscoelastic was removed. Topical antiiotic........
I have for DX: 371.00 364.70 and 366.16
I'm not sure how to code the aborted cataract surgery? 66984-52?
UPDATE:
I am going to bill it like this 66984-52-RT. If anyone has any suggestions or comments I would appreciate it. (I can turn in a corrected claim)
66600 is included......right?
I would appreciate any help I could get with this operative report! I really want to do it right. Thank you!
Hope
ASC Coder in Omaha NE - Go Huskers!
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