maryir
Networker
Please read the note below. The Dr is coding as a 67108 (stating there was no proliferative vitreoretinopathy C-1 or greater. I'm thinking the procedure doesn't require meeting all the dx's within the parentheses and that the procedure meets the 67113.
I've been looking for a definition of how CPT uses parentheses but have not been able to locate one. I did find ICD-10 definition but not CPT. I was sure there was one.
Please read the note and let me know if I'm in my own dream world or is there guidelines that state how to look at data within parentheses.
Thanks
Diagnosis: 1. Recurrent rhegmatogenous retinal detachment with proliferative vitreoretinopathy right eye
2. Vitreous hemorrhage right eye
3. Phakic right eye
4. Myopia right eye
Operation(s): 23 gauge pars plana vitrectomy, retinectomy, endolaser, air fluid exchange, 14% C3F8 right eye
Anesthesia Type: GETA
Indications: presented for evaluation of decreased vision with flashes in the right eye after retinal detachment surgery. A detailed ophthalmic examination revealed findings of vitreous hemorrhage with underlying macula involving inferior retinal detachment. R/B/A to vitrectomy with membrane peel include but are not limited to death, loss of vision, loss of eye, pain, bleeding, infection, need for additional surgery, retinal detachment, accelerated cataract formation, glaucoma, need for corrective lenses, corneal decompensation, and cosmetic disfigurement.
Description of Procedure:
Patient was met in the preoperative holding area where the right eye was confirmed to be the correct eye with both the patient and the consent form. The right eye was then marked and the patient was brought to the operating room where an official time out was performed.
Under the care of the anesthesia team, light IV sedation was administered after which the ophthalmology team performed a retrobulbar block. This consisted of an equal mixture of 2% lidocaine and 0.75% bupivicaine on at Atkinson needle. The eye was then prepped and draped in the sterile ophthalmic fashion, taking care to place povidone-iodine solution in the conjunctival fornices.
Three 23-gauge trocars were then inserted in a beveled fashion, taking care to displace the overlying conjunctiva. The infusion cannula was then placed in the inferotemporal cannula and its placement in the vitreous cavity was confirmed with direct visualization. The light pipe and cutter were then introduced into the eye. Under the ReSIGHT noncontact viewing system, the retina was carefully examined. A core vitrectomy was then performed. A PVD was not present. A PVD was induced with the vitrector. There were areas of abnormal vitreoretinal adhesion inferotemporally and superiorly consistent with lattice degeneration. Retinal tear was visualized at 5 o'clock, 7 o'clock adjacent to an area of pigmented lattice with adherent vitreous, and 10 o'clock. Superiorly there was lattice extending from 11 o'clock to 2:30 with a retinal tear at 11 o'clock. A peripheral vitrectomy was then completed, taking care to remove vitreous traction from each of the tears. The vitreous could not be removed in its entirety from the lattice inferotemporally. Perfluoron was injected over the posterior pole. The decision was made to perform a retinectomy inferiorly from 5 o'clock to 10 o'clock. This was first demarcated with the diathermy and then completed with the vitrector. Perfluoron was then injected for a complete fill and the retina flattened nicely. Endolaser was applied in 3 rows along the retinectomy edge. The superior lattice was also barricaded with 3 concentric rows of endolaser. A complete air-fluid-perfluoron exchange was performed, taking care to drain carefully at the retinectomy edge and then over the nerve. The retina was flat and attached under air. 14% sterile C3F8 was drawn up onto the field and injected into the eye for a complete fill. The trocars were removed and the eye was found to be at physiologic pressure with watertight wounds. Cefuroxime and dexamethasone were injected subconjunctivally and in the peribulbar space. The speculum and drapes were then removed. The eye was then washed and dried. Atropine drops and maxitrol ointment were then placed in the eye. The eye was then patched and shielded. The patient tolerated the procedure well and was transferred back to anesthesia for extubation.
The patient is to maintain facedown positioning until her appointment with Dr. tomorrow morning. Further post-operative instructions will be given at that time.
Estimated Blood Loss: <5mL
Drains: none
Specimens: none
Implants: none
Complications: none
Disposition: PACU - hemodynamically stable.
Condition: stable
I've been looking for a definition of how CPT uses parentheses but have not been able to locate one. I did find ICD-10 definition but not CPT. I was sure there was one.
Please read the note and let me know if I'm in my own dream world or is there guidelines that state how to look at data within parentheses.
Thanks
Diagnosis: 1. Recurrent rhegmatogenous retinal detachment with proliferative vitreoretinopathy right eye
2. Vitreous hemorrhage right eye
3. Phakic right eye
4. Myopia right eye
Operation(s): 23 gauge pars plana vitrectomy, retinectomy, endolaser, air fluid exchange, 14% C3F8 right eye
Anesthesia Type: GETA
Indications: presented for evaluation of decreased vision with flashes in the right eye after retinal detachment surgery. A detailed ophthalmic examination revealed findings of vitreous hemorrhage with underlying macula involving inferior retinal detachment. R/B/A to vitrectomy with membrane peel include but are not limited to death, loss of vision, loss of eye, pain, bleeding, infection, need for additional surgery, retinal detachment, accelerated cataract formation, glaucoma, need for corrective lenses, corneal decompensation, and cosmetic disfigurement.
Description of Procedure:
Patient was met in the preoperative holding area where the right eye was confirmed to be the correct eye with both the patient and the consent form. The right eye was then marked and the patient was brought to the operating room where an official time out was performed.
Under the care of the anesthesia team, light IV sedation was administered after which the ophthalmology team performed a retrobulbar block. This consisted of an equal mixture of 2% lidocaine and 0.75% bupivicaine on at Atkinson needle. The eye was then prepped and draped in the sterile ophthalmic fashion, taking care to place povidone-iodine solution in the conjunctival fornices.
Three 23-gauge trocars were then inserted in a beveled fashion, taking care to displace the overlying conjunctiva. The infusion cannula was then placed in the inferotemporal cannula and its placement in the vitreous cavity was confirmed with direct visualization. The light pipe and cutter were then introduced into the eye. Under the ReSIGHT noncontact viewing system, the retina was carefully examined. A core vitrectomy was then performed. A PVD was not present. A PVD was induced with the vitrector. There were areas of abnormal vitreoretinal adhesion inferotemporally and superiorly consistent with lattice degeneration. Retinal tear was visualized at 5 o'clock, 7 o'clock adjacent to an area of pigmented lattice with adherent vitreous, and 10 o'clock. Superiorly there was lattice extending from 11 o'clock to 2:30 with a retinal tear at 11 o'clock. A peripheral vitrectomy was then completed, taking care to remove vitreous traction from each of the tears. The vitreous could not be removed in its entirety from the lattice inferotemporally. Perfluoron was injected over the posterior pole. The decision was made to perform a retinectomy inferiorly from 5 o'clock to 10 o'clock. This was first demarcated with the diathermy and then completed with the vitrector. Perfluoron was then injected for a complete fill and the retina flattened nicely. Endolaser was applied in 3 rows along the retinectomy edge. The superior lattice was also barricaded with 3 concentric rows of endolaser. A complete air-fluid-perfluoron exchange was performed, taking care to drain carefully at the retinectomy edge and then over the nerve. The retina was flat and attached under air. 14% sterile C3F8 was drawn up onto the field and injected into the eye for a complete fill. The trocars were removed and the eye was found to be at physiologic pressure with watertight wounds. Cefuroxime and dexamethasone were injected subconjunctivally and in the peribulbar space. The speculum and drapes were then removed. The eye was then washed and dried. Atropine drops and maxitrol ointment were then placed in the eye. The eye was then patched and shielded. The patient tolerated the procedure well and was transferred back to anesthesia for extubation.
The patient is to maintain facedown positioning until her appointment with Dr. tomorrow morning. Further post-operative instructions will be given at that time.
Estimated Blood Loss: <5mL
Drains: none
Specimens: none
Implants: none
Complications: none
Disposition: PACU - hemodynamically stable.
Condition: stable
