Hello fellow coders,
Looking for your opinion , any and all will be so appreciated.
Preoperative DX: Recurrent pteryguim, right eye
Post operative DX: same
Operative Procedure: Conjuntival reconstruction
Sub-Tenon's injection, right eye
Following the administration of local anesthesia, the patient was prepped and draped in the usual sterile opthalamic fashion. Next, 2 6-0 Vicryl sutures were placed at the limbus, 1 inferiorly and 1 superiorly, and used to rotate the eye temporally to expose the pterygium nasally. This was removed using a combination of blunt and sharp dissection, and the cornea was polished to remove the remaing tissue. Hemostasis was obtained. Mytomycin-C in a concentrate of 0.04% was palced on the conjunctiva for 2 minutes and then the eye was irrigated copiously. A pedicle graft was taken from the conjuntiva superiorly and swung to cover the conjunctival defect completely. This was secured in place suing a running 8-0 Vicryl suture. Kenalog was injected in a sub-tenon's fashion. The graft was noted to cover the defect completely. A bandaage contact lens was applied and Maxitrol ointment instilled. The eye was patched and shielded. The patient tolerated the procedure well and left the room clean and in good condition.
I coded this as 65426. The physician coded this 65782. I would appreciate any and all opinions in this . I do also plan to query the physician .
Paula
Looking for your opinion , any and all will be so appreciated.
Preoperative DX: Recurrent pteryguim, right eye
Post operative DX: same
Operative Procedure: Conjuntival reconstruction
Sub-Tenon's injection, right eye
Following the administration of local anesthesia, the patient was prepped and draped in the usual sterile opthalamic fashion. Next, 2 6-0 Vicryl sutures were placed at the limbus, 1 inferiorly and 1 superiorly, and used to rotate the eye temporally to expose the pterygium nasally. This was removed using a combination of blunt and sharp dissection, and the cornea was polished to remove the remaing tissue. Hemostasis was obtained. Mytomycin-C in a concentrate of 0.04% was palced on the conjunctiva for 2 minutes and then the eye was irrigated copiously. A pedicle graft was taken from the conjuntiva superiorly and swung to cover the conjunctival defect completely. This was secured in place suing a running 8-0 Vicryl suture. Kenalog was injected in a sub-tenon's fashion. The graft was noted to cover the defect completely. A bandaage contact lens was applied and Maxitrol ointment instilled. The eye was patched and shielded. The patient tolerated the procedure well and left the room clean and in good condition.
I coded this as 65426. The physician coded this 65782. I would appreciate any and all opinions in this . I do also plan to query the physician .
Paula