maryir
Networker
I'm not sure how to code this. Can it be a vitrectomy without removal of vitreous? Am I reading it incorrectly? Dr is coding CPT 67036 and 67121
Three 25-gauge trocars were then inserted in a beveled fashion, taking care to displace the overlying conjunctiva. The infusion cannula was then placed in the inferotemporal cannula and its placement in the vitreous cavity was confirmed with direct visualization. Silicone oil was removed. The light pipe and cutter were then introduced into the eye. Under the ReSIGHT noncontact viewing system, the retina was examined and noted to have significant intraretinal fibrosis along the arcades. The fovea appeared attached. There was perisilicone oil proliferation overlying the fibrosis. Dilute indocyanine green was injected over the posterior pole, allowed to sit for 30-60 seconds, and removed. The drop-on macular contact lens was placed. ILM forceps were used to remove layers of perisilicone oil proliferation overlying the fibrosis. It was noted the fibrosis was intraretinal and could not be removed further. The contact lens was removed, and the the ReSIGHT was brought back into view. Additional air-fluid exchanges were performed, and the retina was left under fluid.
The trocars were removed and the sclerotomies were sutured with 7-0 vicryl. Vannas scissors were used to remove the corneal suture from a prior procedure. Cefuroxime and dexamethasone were injected subconjunctivally. The speculum and drapes were then removed. The eye was then washed and dried. Atropine drops and maxitrol ointment were then placed in the eye. The eye was then patched and shielded. The patient tolerated the procedure well and was transferred to PACU for recovery.
Three 25-gauge trocars were then inserted in a beveled fashion, taking care to displace the overlying conjunctiva. The infusion cannula was then placed in the inferotemporal cannula and its placement in the vitreous cavity was confirmed with direct visualization. Silicone oil was removed. The light pipe and cutter were then introduced into the eye. Under the ReSIGHT noncontact viewing system, the retina was examined and noted to have significant intraretinal fibrosis along the arcades. The fovea appeared attached. There was perisilicone oil proliferation overlying the fibrosis. Dilute indocyanine green was injected over the posterior pole, allowed to sit for 30-60 seconds, and removed. The drop-on macular contact lens was placed. ILM forceps were used to remove layers of perisilicone oil proliferation overlying the fibrosis. It was noted the fibrosis was intraretinal and could not be removed further. The contact lens was removed, and the the ReSIGHT was brought back into view. Additional air-fluid exchanges were performed, and the retina was left under fluid.
The trocars were removed and the sclerotomies were sutured with 7-0 vicryl. Vannas scissors were used to remove the corneal suture from a prior procedure. Cefuroxime and dexamethasone were injected subconjunctivally. The speculum and drapes were then removed. The eye was then washed and dried. Atropine drops and maxitrol ointment were then placed in the eye. The eye was then patched and shielded. The patient tolerated the procedure well and was transferred to PACU for recovery.