Fellow coders:
Do you see any additional code besides the 66984 that is not included, on the report below?
PREOPERATIVE DIAGNOSIS: Cataract and glaucoma, left eye.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED:
1. Phacoemulsification with a loose zonules, therefore placing the posterior chamber lens in the sulcus.
2. Finding that the implant was not held in properly, removal of that posterior chamber lens.
3. Anterior vitrectomy with scissors.
4. Anterior chamber lens implantation.
5. Iridotomy.
6. Limbal relaxing incisions.
ANESTHESIA: Local, standby.
COMPLICATIONS: None.
PROCEDURE IN DETAIL: The patient received a peribulbar block by the anesthesiologist. The patient was brought to the operating room and prepped and draped in the usual manner for an eye case. Attention was turned to the left eye. An eye speculum was placed.
A clear corneal stab incision was made. Viscoelastic was placed in the anterior chamber. A clear corneal keratotomy incision was made. A capsulotomy was made, but it appeared immediately that the capsule was offering no resistance. Therefore, I thought that the patient had loose zonules. A careful anterior capsulotomy was performed for 360° without complications. The nucleus was removed very carefully with first hydrodissection, hydrodelineation and the phacoemulsifier. The cortex was also removed. During the cortical cleanup, it was apparent that the capsule was loose in various areas, and tended to catch into the irrigation-aspiration port while removing cortex. Therefore, I thought that perhaps there was enough zonular support to put a posterior chamber lens in. So, viscoelastic was placed behind the iris and in front of the capsule. The implant was injected into the sulcus, rotated to a horizontal position, and centered well. The I&A handpiece was used to remove viscoelastic from the anterior chamber. It was apparent that the lens was not fixated well, and started to sunset. Therefore, viscoelastic was placed anterior and posterior to the implant. The haptics were brought into the anterior chamber. An implant remover was used to remove the implant in one motion without complication. The capsule was now bunched up into the pupil, and it was removed with a smooth McPherson forceps. An air bubble was placed in the anterior chamber. It appeared that there was a little bit of vitreous at the wound which was cleaned up with a Weck-Cel sponge and scissors. Miostat was placed in the anterior chamber for pupillary constriction. A wire air bubble was used to fill the entire anterior chamber to be sure there was no more vitreous in the anterior chamber, and none at the wound. It was tested with a Weck-Cel to be clear. Viscoelastic was then placed in the anterior chamber to keep the air from escaping. A white-to-white measurement was 11.5 mm. Therefore, an SUV implant was used. The wound was extended with a keratome to 6 mm. The implant was inspected and irrigated. Viscoelastic was placed on the surface and placed into the anterior chamber, in the anterior chamber angle, away from the wound, and then under
Continued
KOERNER, ADOLPH SCS CHART #42452
Page Two
OP - 01-10-11
direct visualization, placed in the angle near the wound. It appeared to center well. The wound was closed with interrupted 10-0 nylon sutures. Further viscoelastic was placed in the anterior chamber. An iridotomy was made with a 23-gauge needle, superiorly. The I&A handpiece was then used to remove the viscoelastic. The remaining wound was closed with interrupted 10-0 nylon. The anterior chamber was filled with balanced salt. The wound was tested to be watertight. Two 50° limbal relaxing incisions were made at 100° without complication. The sutures were buried. A subconjunctival injection of Decadron and Ancef were placed inferonasally.
At the conclusion of the case, the conjunctiva was intact. The cornea was crystal clear. The wound was watertight. The anterior chamber was deep and clear. The anterior chamber lens was central and clear. The pupil was round, regular and small, and the iridotomy was seen superiorly. An antibiotic drop was placed in the eye followed by a patch and shield.
The patient tolerated the procedure well and left the operating room in good condition.
I need feedback...please!
Do you see any additional code besides the 66984 that is not included, on the report below?
PREOPERATIVE DIAGNOSIS: Cataract and glaucoma, left eye.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED:
1. Phacoemulsification with a loose zonules, therefore placing the posterior chamber lens in the sulcus.
2. Finding that the implant was not held in properly, removal of that posterior chamber lens.
3. Anterior vitrectomy with scissors.
4. Anterior chamber lens implantation.
5. Iridotomy.
6. Limbal relaxing incisions.
ANESTHESIA: Local, standby.
COMPLICATIONS: None.
PROCEDURE IN DETAIL: The patient received a peribulbar block by the anesthesiologist. The patient was brought to the operating room and prepped and draped in the usual manner for an eye case. Attention was turned to the left eye. An eye speculum was placed.
A clear corneal stab incision was made. Viscoelastic was placed in the anterior chamber. A clear corneal keratotomy incision was made. A capsulotomy was made, but it appeared immediately that the capsule was offering no resistance. Therefore, I thought that the patient had loose zonules. A careful anterior capsulotomy was performed for 360° without complications. The nucleus was removed very carefully with first hydrodissection, hydrodelineation and the phacoemulsifier. The cortex was also removed. During the cortical cleanup, it was apparent that the capsule was loose in various areas, and tended to catch into the irrigation-aspiration port while removing cortex. Therefore, I thought that perhaps there was enough zonular support to put a posterior chamber lens in. So, viscoelastic was placed behind the iris and in front of the capsule. The implant was injected into the sulcus, rotated to a horizontal position, and centered well. The I&A handpiece was used to remove viscoelastic from the anterior chamber. It was apparent that the lens was not fixated well, and started to sunset. Therefore, viscoelastic was placed anterior and posterior to the implant. The haptics were brought into the anterior chamber. An implant remover was used to remove the implant in one motion without complication. The capsule was now bunched up into the pupil, and it was removed with a smooth McPherson forceps. An air bubble was placed in the anterior chamber. It appeared that there was a little bit of vitreous at the wound which was cleaned up with a Weck-Cel sponge and scissors. Miostat was placed in the anterior chamber for pupillary constriction. A wire air bubble was used to fill the entire anterior chamber to be sure there was no more vitreous in the anterior chamber, and none at the wound. It was tested with a Weck-Cel to be clear. Viscoelastic was then placed in the anterior chamber to keep the air from escaping. A white-to-white measurement was 11.5 mm. Therefore, an SUV implant was used. The wound was extended with a keratome to 6 mm. The implant was inspected and irrigated. Viscoelastic was placed on the surface and placed into the anterior chamber, in the anterior chamber angle, away from the wound, and then under
Continued
KOERNER, ADOLPH SCS CHART #42452
Page Two
OP - 01-10-11
direct visualization, placed in the angle near the wound. It appeared to center well. The wound was closed with interrupted 10-0 nylon sutures. Further viscoelastic was placed in the anterior chamber. An iridotomy was made with a 23-gauge needle, superiorly. The I&A handpiece was then used to remove the viscoelastic. The remaining wound was closed with interrupted 10-0 nylon. The anterior chamber was filled with balanced salt. The wound was tested to be watertight. Two 50° limbal relaxing incisions were made at 100° without complication. The sutures were buried. A subconjunctival injection of Decadron and Ancef were placed inferonasally.
At the conclusion of the case, the conjunctiva was intact. The cornea was crystal clear. The wound was watertight. The anterior chamber was deep and clear. The anterior chamber lens was central and clear. The pupil was round, regular and small, and the iridotomy was seen superiorly. An antibiotic drop was placed in the eye followed by a patch and shield.
The patient tolerated the procedure well and left the operating room in good condition.
I need feedback...please!