Jenannurb
Contributor
Hello all.
I am new to ASC coding and eye surgery is proving to be a challenge for me.
would you please look at the op note and give me your thoughts on how to code it?
I was going with 67018 and 67025 -
********
PREOPERATIVE DIAGNOSIS:
Rhegmatogenous retinal detachment, right eye.
*
POSTOPERATIVE DIAGNOSIS:
Rhegmatogenous retinal detachment, right eye.
*
OPERATIVE PROCEDURE:
Repair of rhegmatogenous retinal detachment, right eye, by scleral buckle, pars plana vitrectomy, endolaser, and 14% C3F8 gas.
*
SURGEON:
Leon Charkoudian, M.D.
*
ASSISTANT:
Staff.
*
ANESTHESIA:
General with peribulbar block.
*
FLUID:
Per Anesthesia.
*
ESTIMATED BLOOD LOSS:
Minimal.
*
DRAINS:
None.
*
SPECIMENS:
None.
*
COMPLICATIONS:
None.
*
INDICATIONS:
The patient presented to my clinic with a decrease in vision of the right eye of several days in duration. The patient was examined and found to have a macula-off rhegmatogenous retinal detachment. The risks, benefits, alternatives to surgical repair were discussed with the patient. The patient agreed and wished to proceed. Informed consent was signed.
*
OPERATIVE PROCEDURE IN DETAIL:
The patient was identified as the correct patient in the preoperative holding area and the right eye was marked for surgery. The patient was taken back to the operating room by anesthesia staff where general anesthesia was initiated. A time-out was performed to confirm the right eye for surgery. The eye was then prepped and draped in usual sterile fashion. A speculum was placed in the right eye. A 360-degree conjunctival peritomy was created using Westcott scissors. The quadrants were cleared using blunt Stevens scissors. A gentle peribulbar block was placed inferotemporally with a blunt cannula. The four horizontal and vertical rectus muscles were isolated using 2-0 silk ties. The eye was inspected and found to be slightly large without significant scleral thinning. A 42 band and 72 sleeve were chosen and irrigated with antibiotic solution. The band was then passed beneath the four rectus muscles and secured superonasally with the sleeve. The band was inspected and found not to be rotated. The band was then sutured down in all four quadrants using a 5-0 nylon suture in a horizontal mattress fashion. The band was placed to support the vitreous base for 360 degrees. All knots were rotated posteriorly. The band was then pulled up to provide moderate indentation.
*
A standard 3-port 25-gauge vitrectomy was then established with the infusion in the inferior temporal quadrant. The infusion cannula was inspected prior to initiation of infusion and found to be unobstructed. Under visualization of the binocular indirect ophthalmic microscope, the findings of a total, macula-off rhegmatogenous retinal detachment were confirmed. There were multiple retinal breaks (eight) spanning temporally and superiorly from 6 to 1 o'clock. The breaks appeared well-supported by the buckle. A posterior vitreous detachment was present. A core vitrectomy was performed. A thorough peripheral shave vitrectomy was performed for 360 degrees, including trimming of vitreous from around the retinal breaks. No obvious proliferative vitreo-retinopathy was seen. A superior posterior retinotomy was created using a soft-tipped cannula. The breaks and the retinotomy were marked with intraocular diathermy. A complete air-fluid exchange was then performed, and repeated a minute later to remove any residual fluid. Following the air-fluid exchange, the retina appeared flat for 360 degrees wtihout significant subretinal fluid. Endolaser was applied around the retinal breaks and the retinotomy and scattered on the flat aspect of the buckle for 360 degrees. The instruments were removed and the eye was plugged. The superonasal trocar was removed, and its sclerotomy was closed using 7-0 vicryl suture. The air was exchanged for sterile 14% C3F8 gas. The remaining trocars were removed, and the remaining sclerotomies were closed using 7-0 vicryl suture. The buckle ends were trimmed. The eye was palpated and found to be normotensive. The silk sutures were removed and the conjunctiva was then closed using 7-0 vicryl suture. Subconjunctival injections of antibiotic and steroid were applied. The speculum was removed. Antibiotic ointment was applied. The eye was patched and shielded. The patient was taken to postop recovery unit in stable condition. There were no complications. The patient was instructed to keep the patch and shield in place, to maintain face down positioning at all times, and to follow with me tomorrow in clinic. It was not necessary to scrape the corneal epithelium during this case.*******
*
I am new to ASC coding and eye surgery is proving to be a challenge for me.
would you please look at the op note and give me your thoughts on how to code it?
I was going with 67018 and 67025 -
********
PREOPERATIVE DIAGNOSIS:
Rhegmatogenous retinal detachment, right eye.
*
POSTOPERATIVE DIAGNOSIS:
Rhegmatogenous retinal detachment, right eye.
*
OPERATIVE PROCEDURE:
Repair of rhegmatogenous retinal detachment, right eye, by scleral buckle, pars plana vitrectomy, endolaser, and 14% C3F8 gas.
*
SURGEON:
Leon Charkoudian, M.D.
*
ASSISTANT:
Staff.
*
ANESTHESIA:
General with peribulbar block.
*
FLUID:
Per Anesthesia.
*
ESTIMATED BLOOD LOSS:
Minimal.
*
DRAINS:
None.
*
SPECIMENS:
None.
*
COMPLICATIONS:
None.
*
INDICATIONS:
The patient presented to my clinic with a decrease in vision of the right eye of several days in duration. The patient was examined and found to have a macula-off rhegmatogenous retinal detachment. The risks, benefits, alternatives to surgical repair were discussed with the patient. The patient agreed and wished to proceed. Informed consent was signed.
*
OPERATIVE PROCEDURE IN DETAIL:
The patient was identified as the correct patient in the preoperative holding area and the right eye was marked for surgery. The patient was taken back to the operating room by anesthesia staff where general anesthesia was initiated. A time-out was performed to confirm the right eye for surgery. The eye was then prepped and draped in usual sterile fashion. A speculum was placed in the right eye. A 360-degree conjunctival peritomy was created using Westcott scissors. The quadrants were cleared using blunt Stevens scissors. A gentle peribulbar block was placed inferotemporally with a blunt cannula. The four horizontal and vertical rectus muscles were isolated using 2-0 silk ties. The eye was inspected and found to be slightly large without significant scleral thinning. A 42 band and 72 sleeve were chosen and irrigated with antibiotic solution. The band was then passed beneath the four rectus muscles and secured superonasally with the sleeve. The band was inspected and found not to be rotated. The band was then sutured down in all four quadrants using a 5-0 nylon suture in a horizontal mattress fashion. The band was placed to support the vitreous base for 360 degrees. All knots were rotated posteriorly. The band was then pulled up to provide moderate indentation.
*
A standard 3-port 25-gauge vitrectomy was then established with the infusion in the inferior temporal quadrant. The infusion cannula was inspected prior to initiation of infusion and found to be unobstructed. Under visualization of the binocular indirect ophthalmic microscope, the findings of a total, macula-off rhegmatogenous retinal detachment were confirmed. There were multiple retinal breaks (eight) spanning temporally and superiorly from 6 to 1 o'clock. The breaks appeared well-supported by the buckle. A posterior vitreous detachment was present. A core vitrectomy was performed. A thorough peripheral shave vitrectomy was performed for 360 degrees, including trimming of vitreous from around the retinal breaks. No obvious proliferative vitreo-retinopathy was seen. A superior posterior retinotomy was created using a soft-tipped cannula. The breaks and the retinotomy were marked with intraocular diathermy. A complete air-fluid exchange was then performed, and repeated a minute later to remove any residual fluid. Following the air-fluid exchange, the retina appeared flat for 360 degrees wtihout significant subretinal fluid. Endolaser was applied around the retinal breaks and the retinotomy and scattered on the flat aspect of the buckle for 360 degrees. The instruments were removed and the eye was plugged. The superonasal trocar was removed, and its sclerotomy was closed using 7-0 vicryl suture. The air was exchanged for sterile 14% C3F8 gas. The remaining trocars were removed, and the remaining sclerotomies were closed using 7-0 vicryl suture. The buckle ends were trimmed. The eye was palpated and found to be normotensive. The silk sutures were removed and the conjunctiva was then closed using 7-0 vicryl suture. Subconjunctival injections of antibiotic and steroid were applied. The speculum was removed. Antibiotic ointment was applied. The eye was patched and shielded. The patient was taken to postop recovery unit in stable condition. There were no complications. The patient was instructed to keep the patch and shield in place, to maintain face down positioning at all times, and to follow with me tomorrow in clinic. It was not necessary to scrape the corneal epithelium during this case.*******
*