OK Mary....so I think I have myself confused about the pre-existing astigmatism. Can you look at this report and tell me can I code the astigmatism or not? I'm thinking that I can w/mod 59 because he stated the astigmatism as pre and post op dx but I am not 100% sure.
PREOPERATIVE DIAGNOSES:
1. Nuclear sclerotic cataract, left eye.
2. Astigmatism, left eye.
POSTOPERATIVE DIAGNOSES:
1. Nuclear sclerotic cataract, left eye.
2. Astigmatism, left eye.
OPERATION:
Phacoemulsification with intraocular lens implantation, left eye.
ANESTHESIA:
Monitored anesthesia care with topical.
COMPLICATIONS:
None.
DESCRIPTION OF PROCEDURE:
After identifying the patient in the preoperative holding area, the patient was brought into the operative room where a small dose of intravenous medication was given for sedation. After sedation, several drops of 4% nonpreserved Xylocaine were placed into the left eye. After adequate anesthesia, the patient was prepped and draped in a sterile fashion.
A lid speculum was placed into the left eye after which a #75 blade was used to make a paracentesis and approximately 0.5 mL of a 1:3 mixture of 4% non-preservative Xylocaine and sterile BSS was injected into the anterior chamber. The anterior chamber was next filled with viscoelastic after which a 3-mm keratome was used to enter the anterior chamber through the temporal, peripheral clear cornea.
A cystitome needle was used to make a small anterior capsulotomy after which a 360-degree circular continuous capsulorrhexis was made with Utrata forceps. BSS on a cannula was used to hydrodissect the lens nucleus, after which the nucleus was phacoemulsified.
The I/A unit was used to remove any remaining lens material from the anterior chamber, after which the capsular bag was filled with viscoelastic and the lens, an Alcon model SN60T3 22.5-diopter lens was placed into the capsular bag and dialed 90 degrees without incident. The I/A was placed back into the anterior chamber and any remaining lens material and viscoelastic was aspirated from the eye.
The wounds were checked and found to be watertight, and the eye pressure was found to be adequate. The lid speculum and drapes were removed after which one drop of 1% Iopidine and one drop of 0.75% carbachol were placed along with several drops of Ciloxan eyedrops. A shield was placed over the eye, and the patient was sent to the recovery room in stable condition.
The patient was instructed to use Ciloxan eye drops every 2 hours while awake after surgery and to call Dr. Cohen for any problems. An appointment was given for the following morning.
ADDENDUM:
This patient had preexisting astigmatism for which she elected to have an astigmatism correcting lens implanted. Prior to surgery, the vertical axis of astigmatism was measured with the patient in a seated upright position. Prior to lens implantation, the axis of astigmatism was marked on the patient's cornea and the lens was placed into the capsular bag and rotated into alignment with the axis. This was confirmed to be in alignment at the end of the case.
Thank you once again!!
Susan
