coder25
Guru
Hi everyone!
I am new to vision coding and was hoping someone could help me with this OP note:
The patient had an intraocular lens implanted in August and now returns with revision of incision and attempted removal of foreign body:
The pt was brought to the OR and prepped and draped in the usual sterile fashion. A speculum was applied A microscope was brought into position of the left eye.
A small fiber-type foreign body was noted and the site of the prior incision. A 2.4 keratome was used to reopen the incision. Tooth forceps, as well as a foreign body probe was used to attempt to remove the small fiber in the incision. The fiber had significant corneal ingrowth and attempt to remove it was unsuccessful; without further disrupting the architecture of the incision.
An attempt was made to irrigate the incision to remove the foreign body without good results. At this time, it was decided that the foreign body was deep, appeared inert, with significant corneal ingrowth; and removal would require significant disruption of the clear corneal incision with possible poor vision results. The incision was hydrated with BSS. A single 10-0 nylon suture was placed at the incision site to ensure watertightness. The wound was noted to be sealed. A C was noted to be deep. Intraocular lens implant from prior surgery remained in good potion, and a small fibrous foreign body was still noted at the incision site.
At the end of the case, the intraocular pressure was noted to be physiologic and the chamber well formed. The patient tolerated the procedure well and left the OR in stable condition.
Would I use 65222 with a 53 modifier? is there a code for the revision?
Thanks in advance for your help!
I am new to vision coding and was hoping someone could help me with this OP note:
The patient had an intraocular lens implanted in August and now returns with revision of incision and attempted removal of foreign body:
The pt was brought to the OR and prepped and draped in the usual sterile fashion. A speculum was applied A microscope was brought into position of the left eye.
A small fiber-type foreign body was noted and the site of the prior incision. A 2.4 keratome was used to reopen the incision. Tooth forceps, as well as a foreign body probe was used to attempt to remove the small fiber in the incision. The fiber had significant corneal ingrowth and attempt to remove it was unsuccessful; without further disrupting the architecture of the incision.
An attempt was made to irrigate the incision to remove the foreign body without good results. At this time, it was decided that the foreign body was deep, appeared inert, with significant corneal ingrowth; and removal would require significant disruption of the clear corneal incision with possible poor vision results. The incision was hydrated with BSS. A single 10-0 nylon suture was placed at the incision site to ensure watertightness. The wound was noted to be sealed. A C was noted to be deep. Intraocular lens implant from prior surgery remained in good potion, and a small fibrous foreign body was still noted at the incision site.
At the end of the case, the intraocular pressure was noted to be physiologic and the chamber well formed. The patient tolerated the procedure well and left the OR in stable condition.
Would I use 65222 with a 53 modifier? is there a code for the revision?
Thanks in advance for your help!