Post Op: Retained lens fragment, left eye
Procedure: Removal of the retained lens fragment, left eye
Description:
After the patient was seen and identified in the preop holding area, the left eye was marked for left monocular surgery. The patient was taken to operating room and placed on the table in the supine position. Topical lidocaine jelly and antibiotic had been placed on the eye. The patient's left eye was then carefully prepped and draped in the usual fashion. The lid speculum was then placed on the left eye. A superior paracentesis was made using side port blade. Viscoelastic was then placed into the eye through hold the lens fragment inferiorly, where it had been stable for several weeks. An additional paracentesis was made inferiorly. Then using bimanual irrigation-aspiration hadpieces, the viscoelastic was removed from the eye and the nuclear piece was easily aspirated from the anterior chamber. The anterior chamber was then inflated with viscoelastic to normal pressure. The wounds were checked and found to be watertight. The anterior chamber was deep. The patient tolerated the procedure well and was taken to the recovery in stable condition.
I need some input as to what code would be correct. 66840 is for aspiration, but only a fragment was removed so I was looking at 65235. Any help is greatly appreciated!!
Procedure: Removal of the retained lens fragment, left eye
Description:
After the patient was seen and identified in the preop holding area, the left eye was marked for left monocular surgery. The patient was taken to operating room and placed on the table in the supine position. Topical lidocaine jelly and antibiotic had been placed on the eye. The patient's left eye was then carefully prepped and draped in the usual fashion. The lid speculum was then placed on the left eye. A superior paracentesis was made using side port blade. Viscoelastic was then placed into the eye through hold the lens fragment inferiorly, where it had been stable for several weeks. An additional paracentesis was made inferiorly. Then using bimanual irrigation-aspiration hadpieces, the viscoelastic was removed from the eye and the nuclear piece was easily aspirated from the anterior chamber. The anterior chamber was then inflated with viscoelastic to normal pressure. The wounds were checked and found to be watertight. The anterior chamber was deep. The patient tolerated the procedure well and was taken to the recovery in stable condition.
I need some input as to what code would be correct. 66840 is for aspiration, but only a fragment was removed so I was looking at 65235. Any help is greatly appreciated!!