AlaskanCoder
Guru
There are 3 different opinions on the coding of this out-patient procedure for both CPT and ICD-9 coding. Personally, I think it is pretty clear, but would appreciate some input:
PREOPERATIVE DIAGNOSIS: Cataract with zonular dehiscence, left eye
POSTOPERATIVE DIAGNOSIS: Catraract with zonular dehiscence, left eye
ANESTHESIA: General
PROCEDURE: Pars plana vitrectomy with pars plana lensectomy and placement of anterior chamber lens, left eye
COMPLICATIONS: None
INDICATION FOR PROCEDURE: The patient was recently referred to our clinic with retinal detachment of his left eye. This was repaired in 1994 by Dr. S. Recently, he developed visually significant cataract in each eye. His doctor is at Medical Center determined that the cataract in the left eye had zonular dehiscence and represented high-risk for phacoemulsification. They referred him for a lensectomy and placement of the lens into the eye. Risks and benefits of surgery were discussed preoperatively.
SUMMARY OF THE CASE: Initially, the patient was identified in the preoperative waiting area. He was transported to the operative suite, where he was placed under general anesthesia. Left eye was prepped and draped for intraocular surgery in a standard fashion. A rigid lid speculum was placed. A superior conjunctival peritomy was performed using 0.12 forceps and Westcott scissors. Hemostasis was obtained using electrocautery. A 4-mm limbal incision was formed with a 75 blade. This was shelved into the clear cornea with a 66 blade. Anterior chamber was entered at the 2 o'clock position with the 75 blade. The anterior chamber was again entered through the superior incision with a keratome. Healon was instilled into the eye reforming the anterior chamber. A 360 degree capsulorrhexis was performed using the cystotome needle and Utrata forceps. The capsulorrhexis was able to be completed without complication. The patient had evidence of temporal zonular dehiscence. The lens nucleus was gently hydrodissected using balanced saline solution.
During phacoemulsification it was evident that the patient had approximately 6 hours of zonular dehiscence. The lens was extremely unstable. Small amount of vitreous presented anteriorly. This was removed using Weck-Cel and Westcott scissors, and it was determined there was not enough support for a posterior chamber lens. It was elected to perform pars plana vitrectomy and remove the lens capsule in addition to the residual cortical material. The superior incision was closed with one 10-0 nylon suture placed interrupted fashion. The vitrectomy was then approached. The indirect viewing system was used for visualization. A 25-guage infusion port was placed at 4-mm posterior to the limbus inferotemporally. The infusion cannula was visualized directly prior to beginning the infusion. Two 25-guage ports were placed at the 10 o'clock and 2 o'clock positions superiorly at 4-mm posterior to the limbus. Initially, deep pars plana vitrectomy was performed. Posterior vitreous detachment had previously occurred. Vitrectomy was carried into the mid to far periphery without complication. The lens capsule and the cortical material was removed using the vitrector anteriorly. Majority of the capsule was removed temporally where the area of dialysis was. The lens capsule was turned into the far periphery nasally. Once vitrectomy and removal of the lens capsule was complete, the ports were plugged. Also noted that he retina was examined with the indirect opthalmoscope. There was no sign of new retinal tear detachment. The superior incision was enlarged to approximately 5-mm using the 66 blade. The pupil was constricted using Miochol. The healon was instilled into the anterior chamber. Iridotomy was performed superior nasally using 0.12 forceps and Vannas scissors. The sheets glide was utilized to place a 7.0 diopter MTA4UO lens anterior to the iris plane. It was gently rotated into position using a Sinskey hook. The corneal diameter of approximately 12-mm appeared adequate for the MTA4UO lens. The superior incision was closed using interrupted 10-0 nylon sutures. The residual viscoelastic was removed from the eye using the IA system. The ports were removed and the 3 sclerotomies required 7-0 Vicryl suture placed interrupted fashion for closure. The eye maintained its pressure and the wounds were found to be watertight. The conjunctival layer was closed using interrupted 7-0 Vicryl sutures. A subconjunctival injection of 50 mg of Ancef was given. The rigid lid speculum was removed. Maxitrol ophthalmic ointment was placed over the eye, the eye was lightly patched and a Fox shield was placed. The patient tolerated the procedure well and was transported to the operative recovery room in stable condition.
PREOPERATIVE DIAGNOSIS: Cataract with zonular dehiscence, left eye
POSTOPERATIVE DIAGNOSIS: Catraract with zonular dehiscence, left eye
ANESTHESIA: General
PROCEDURE: Pars plana vitrectomy with pars plana lensectomy and placement of anterior chamber lens, left eye
COMPLICATIONS: None
INDICATION FOR PROCEDURE: The patient was recently referred to our clinic with retinal detachment of his left eye. This was repaired in 1994 by Dr. S. Recently, he developed visually significant cataract in each eye. His doctor is at Medical Center determined that the cataract in the left eye had zonular dehiscence and represented high-risk for phacoemulsification. They referred him for a lensectomy and placement of the lens into the eye. Risks and benefits of surgery were discussed preoperatively.
SUMMARY OF THE CASE: Initially, the patient was identified in the preoperative waiting area. He was transported to the operative suite, where he was placed under general anesthesia. Left eye was prepped and draped for intraocular surgery in a standard fashion. A rigid lid speculum was placed. A superior conjunctival peritomy was performed using 0.12 forceps and Westcott scissors. Hemostasis was obtained using electrocautery. A 4-mm limbal incision was formed with a 75 blade. This was shelved into the clear cornea with a 66 blade. Anterior chamber was entered at the 2 o'clock position with the 75 blade. The anterior chamber was again entered through the superior incision with a keratome. Healon was instilled into the eye reforming the anterior chamber. A 360 degree capsulorrhexis was performed using the cystotome needle and Utrata forceps. The capsulorrhexis was able to be completed without complication. The patient had evidence of temporal zonular dehiscence. The lens nucleus was gently hydrodissected using balanced saline solution.
During phacoemulsification it was evident that the patient had approximately 6 hours of zonular dehiscence. The lens was extremely unstable. Small amount of vitreous presented anteriorly. This was removed using Weck-Cel and Westcott scissors, and it was determined there was not enough support for a posterior chamber lens. It was elected to perform pars plana vitrectomy and remove the lens capsule in addition to the residual cortical material. The superior incision was closed with one 10-0 nylon suture placed interrupted fashion. The vitrectomy was then approached. The indirect viewing system was used for visualization. A 25-guage infusion port was placed at 4-mm posterior to the limbus inferotemporally. The infusion cannula was visualized directly prior to beginning the infusion. Two 25-guage ports were placed at the 10 o'clock and 2 o'clock positions superiorly at 4-mm posterior to the limbus. Initially, deep pars plana vitrectomy was performed. Posterior vitreous detachment had previously occurred. Vitrectomy was carried into the mid to far periphery without complication. The lens capsule and the cortical material was removed using the vitrector anteriorly. Majority of the capsule was removed temporally where the area of dialysis was. The lens capsule was turned into the far periphery nasally. Once vitrectomy and removal of the lens capsule was complete, the ports were plugged. Also noted that he retina was examined with the indirect opthalmoscope. There was no sign of new retinal tear detachment. The superior incision was enlarged to approximately 5-mm using the 66 blade. The pupil was constricted using Miochol. The healon was instilled into the anterior chamber. Iridotomy was performed superior nasally using 0.12 forceps and Vannas scissors. The sheets glide was utilized to place a 7.0 diopter MTA4UO lens anterior to the iris plane. It was gently rotated into position using a Sinskey hook. The corneal diameter of approximately 12-mm appeared adequate for the MTA4UO lens. The superior incision was closed using interrupted 10-0 nylon sutures. The residual viscoelastic was removed from the eye using the IA system. The ports were removed and the 3 sclerotomies required 7-0 Vicryl suture placed interrupted fashion for closure. The eye maintained its pressure and the wounds were found to be watertight. The conjunctival layer was closed using interrupted 7-0 Vicryl sutures. A subconjunctival injection of 50 mg of Ancef was given. The rigid lid speculum was removed. Maxitrol ophthalmic ointment was placed over the eye, the eye was lightly patched and a Fox shield was placed. The patient tolerated the procedure well and was transported to the operative recovery room in stable condition.