leren44
Guest
I need some input please. I have an op report for a PPV with removal of retained lens fragments, a lensectomy and lens insertion with scleral fixation. The surgeon states the diagnosis as symptomatic retained lens fragments.
In the indication the surgeon states " During cataract surgery last wee, he was found to have no capsular support and retained lens material"
He goes on to do a PPV and removes the retained lens material documenting: "Standard three port vitrectomy was set up at points 3 mm posterior to the limbus. The infusion line was visualized in the vitreous cavity before it was turned on. Fluffy lens material was noted in the visual axis behind the iris. A core vitrectomy was performed. The lens and remaing lens capsule was removed in its entirety with the vitreous cutter. Vitreous was removed as far peripherly as safely possible. A double-armed 10-0 prolene suture was then passed beneath the two scleral flaps. The suture was then pulled out through the scleral tunnel superiourly and cut in half. Each half of the suture was tied onto the eyelet of the lens. The anterior cham ber was filled with Healon and the IOL was inserted into the eye and behind the iris and nicely centered."
I'm thinking 67036 for the removal of retained lens (998.82) but from there i'm not sure. Since he removed the lens and capsule in its entirity and then inserted an IOL, would I use 66986? Or should I code 66985 since he removed lens material in the PPV? Then i'm lost as to what diagnosis to code for the lens removal/insertion. Any suggestions?
Thanks!
In the indication the surgeon states " During cataract surgery last wee, he was found to have no capsular support and retained lens material"
He goes on to do a PPV and removes the retained lens material documenting: "Standard three port vitrectomy was set up at points 3 mm posterior to the limbus. The infusion line was visualized in the vitreous cavity before it was turned on. Fluffy lens material was noted in the visual axis behind the iris. A core vitrectomy was performed. The lens and remaing lens capsule was removed in its entirety with the vitreous cutter. Vitreous was removed as far peripherly as safely possible. A double-armed 10-0 prolene suture was then passed beneath the two scleral flaps. The suture was then pulled out through the scleral tunnel superiourly and cut in half. Each half of the suture was tied onto the eyelet of the lens. The anterior cham ber was filled with Healon and the IOL was inserted into the eye and behind the iris and nicely centered."
I'm thinking 67036 for the removal of retained lens (998.82) but from there i'm not sure. Since he removed the lens and capsule in its entirity and then inserted an IOL, would I use 66986? Or should I code 66985 since he removed lens material in the PPV? Then i'm lost as to what diagnosis to code for the lens removal/insertion. Any suggestions?
Thanks!