I am in need of assistance on the proper coding for this op note. Can someone please direct me in the right direction. Here is the op note:
PRE OPERATIVE DIAGNOSIS: Mature cataract OS
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Clear Corneal Phacoemulsification, Anterior Vitrectomy, Intraocular OS
PROCEDURE: The patient, procedure and site were identified upon entering the OR suite by the surgeon. Under excellent topical anesthesia to the left eye, the left eye was prepped and draped in the usual sterile ophthalmic fashion. It was noted that the eyelids were somewhat floppy and bulky. A paracentesis tract was made superotemporally followed by intracameral injection of Shugarcaine mix .2ml and Viscoelastic was placed in the anterior chamber. A 2.2 keratome was used through the temporal clear cornea incision approximately 90 degrees away from the paracentesis tract. The anterior capsulotomy was performed utilizing capsulorrhexis technique followed by hydrodissection of the nucleus. Phacoemulsification was completed in time utilizing posterior chamber, iris plane, carousel and 2-handed sector anterior-posterior technique. It was note towards the end of the phacoemulsification with approximately a 1/8 piece of the hard nucleus left that there was a break in the inferior capsule and vitreous presented. The procedure was stopped. Viscoelastic was placed in the eye to stabilize the eye. Triescence was instilled in the eye to identify vitreous strands. Another paracentesis tract was made at approximately 2:00 to facilitate bimanual Vitrectomy and the bimanual irrigation-aspiration. Bimanual vitrectomy was carried out removing the central anterior vitreous at the pupil and then to the anterior core of the central part of the vitreous cavity. There was no vitreous to the wound at this time. Careful bimanual irrigation-aspiration was performed to remove some residual cortex, followed by instillation of Visco and Provisc in the anterior chamber. It was decided to place a 3-piece Johnson and Johnson posterior chamber lens. The residual Viscoelastic was removed by irrigation-aspiration. All wound were sealed and bandage contact lens was placed. The lens was well centered, and the eye looked good with wounds secure. The speculum was removed. Patient tolerated the procedure well and left the OR in satisfactory condition.
I am thinking codes 67042 & 66984.
Please offer your assistance!
Thank you,
Cheryl B.
PRE OPERATIVE DIAGNOSIS: Mature cataract OS
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Clear Corneal Phacoemulsification, Anterior Vitrectomy, Intraocular OS
PROCEDURE: The patient, procedure and site were identified upon entering the OR suite by the surgeon. Under excellent topical anesthesia to the left eye, the left eye was prepped and draped in the usual sterile ophthalmic fashion. It was noted that the eyelids were somewhat floppy and bulky. A paracentesis tract was made superotemporally followed by intracameral injection of Shugarcaine mix .2ml and Viscoelastic was placed in the anterior chamber. A 2.2 keratome was used through the temporal clear cornea incision approximately 90 degrees away from the paracentesis tract. The anterior capsulotomy was performed utilizing capsulorrhexis technique followed by hydrodissection of the nucleus. Phacoemulsification was completed in time utilizing posterior chamber, iris plane, carousel and 2-handed sector anterior-posterior technique. It was note towards the end of the phacoemulsification with approximately a 1/8 piece of the hard nucleus left that there was a break in the inferior capsule and vitreous presented. The procedure was stopped. Viscoelastic was placed in the eye to stabilize the eye. Triescence was instilled in the eye to identify vitreous strands. Another paracentesis tract was made at approximately 2:00 to facilitate bimanual Vitrectomy and the bimanual irrigation-aspiration. Bimanual vitrectomy was carried out removing the central anterior vitreous at the pupil and then to the anterior core of the central part of the vitreous cavity. There was no vitreous to the wound at this time. Careful bimanual irrigation-aspiration was performed to remove some residual cortex, followed by instillation of Visco and Provisc in the anterior chamber. It was decided to place a 3-piece Johnson and Johnson posterior chamber lens. The residual Viscoelastic was removed by irrigation-aspiration. All wound were sealed and bandage contact lens was placed. The lens was well centered, and the eye looked good with wounds secure. The speculum was removed. Patient tolerated the procedure well and left the OR in satisfactory condition.
I am thinking codes 67042 & 66984.
Please offer your assistance!
Thank you,
Cheryl B.