I need to get some input as to correct coding for this one. It's a Medicare patient and I work at an ASC. I'm quite stumped!!
PREOPERATIVE DIAGNOSES:
1. Thyroid ophthalmopathy.
2. Exotropia.
3. Left hypertrophia.
4. Status post glaucoma shunt device x2, left eye.
5. Pseudophakia, left eye.
POSTOPERATIVE DIAGNOSES:
1. Thyroid ophthalmopathy.
2. Exotropia.
3. Left hypertrophia.
4. Status post glaucoma shunt device x2, left eye.
5. Pseudophakia, left eye.
PROCEDURES PERFORMED:
1. Bilateral lateral rectus recession.
2. Left inferior rectus recession.
3. Right superior rectus recession.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room suite in stable condition and inducted under general anesthesia without complications. Both eyes were prepped and draped in the usual sterile ophthalmic fashion.
An inferotemporal fornix incision was created to enter conjunctiva and Tenon's capsule of the right eye. A Stevens' hook followed by a Jameson hook was used to hook the lateral rectus muscle. The anterior Tenon's capsule and intermuscular septum were sharply dissected against the muscle belly. A 6‑0 Vicryl double‑armed suture on S29 spatula needle was used to imbricate the muscle belly at its insertion site using a locking bite at either edge of the muscle. The muscle was disinserted from the globe and then placed on an adjustable suture apparatus. A single 6‑0 Mersilene suture was placed at the superior edge of the original insertion site to serve as a traction suture.
A Stevens' hook followed by a Jameson hook was then used to hook the inferior rectus muscle of the right eye. The anterior Tenon's capsule and intermuscular septum were sharply dissected against the muscle belly going 14 mm posterior to the original insertion site. A 6‑0 Mersilene suture on S14 spatula needle was used to imbricate the muscle belly at its insertion site using a locking bite at either edge of the muscle. The muscle was disinserted from the globe and then placed on an adjustable suture apparatus.
Attention was then turned to the left eye. Then, 7 mm posterior to the limbus, the conjunctiva was incised. It was noted that there were two large scleral patch grafts previously placed in association with two glaucoma shunt tubes. The scleral patch grafts were placed over the medial and lateral borders of the superior rectus insertion site. The two arcade vessels were identified. A single "snip incision" was made between the arcade vessels. Care was taken not to incise either ciliary artery. A central myotomy was placed roughly 3 mm in length. Then, 6‑0 plain gut suture was used to close the conjunctiva.
The right eye was patched after placing Maxitrol. The patient tolerated the procedure well. There were no complications.
PREOPERATIVE DIAGNOSES:
1. Thyroid ophthalmopathy.
2. Exotropia.
3. Left hypertrophia.
4. Status post glaucoma shunt device x2, left eye.
5. Pseudophakia, left eye.
POSTOPERATIVE DIAGNOSES:
1. Thyroid ophthalmopathy.
2. Exotropia.
3. Left hypertrophia.
4. Status post glaucoma shunt device x2, left eye.
5. Pseudophakia, left eye.
PROCEDURES PERFORMED:
1. Bilateral lateral rectus recession.
2. Left inferior rectus recession.
3. Right superior rectus recession.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room suite in stable condition and inducted under general anesthesia without complications. Both eyes were prepped and draped in the usual sterile ophthalmic fashion.
An inferotemporal fornix incision was created to enter conjunctiva and Tenon's capsule of the right eye. A Stevens' hook followed by a Jameson hook was used to hook the lateral rectus muscle. The anterior Tenon's capsule and intermuscular septum were sharply dissected against the muscle belly. A 6‑0 Vicryl double‑armed suture on S29 spatula needle was used to imbricate the muscle belly at its insertion site using a locking bite at either edge of the muscle. The muscle was disinserted from the globe and then placed on an adjustable suture apparatus. A single 6‑0 Mersilene suture was placed at the superior edge of the original insertion site to serve as a traction suture.
A Stevens' hook followed by a Jameson hook was then used to hook the inferior rectus muscle of the right eye. The anterior Tenon's capsule and intermuscular septum were sharply dissected against the muscle belly going 14 mm posterior to the original insertion site. A 6‑0 Mersilene suture on S14 spatula needle was used to imbricate the muscle belly at its insertion site using a locking bite at either edge of the muscle. The muscle was disinserted from the globe and then placed on an adjustable suture apparatus.
Attention was then turned to the left eye. Then, 7 mm posterior to the limbus, the conjunctiva was incised. It was noted that there were two large scleral patch grafts previously placed in association with two glaucoma shunt tubes. The scleral patch grafts were placed over the medial and lateral borders of the superior rectus insertion site. The two arcade vessels were identified. A single "snip incision" was made between the arcade vessels. Care was taken not to incise either ciliary artery. A central myotomy was placed roughly 3 mm in length. Then, 6‑0 plain gut suture was used to close the conjunctiva.
The right eye was patched after placing Maxitrol. The patient tolerated the procedure well. There were no complications.
