Could an unspecified capsulorrhexis completed warrant a complex cataract surgery CPT 66982 as only the procedure title mentions "posterior" chamber intraocular lens implant? Or would the correct CPT code be 66984 in this OP report example?
PREOPERATIVE DIAGNOSIS:
Cataract, Right eye
POSTOPERATIVE DIAGNOSIS:
Cataract, Right eye
FINDINGS: Cataract, Right eye
PROCEDURE: Phacoemulsification posterior chamber intraocular
lens implant, Right eye.
ANESTHESIA: Subconjunctival block
INDICATIONS: This patient with a visually significant cataract in the right eye interfering with the
ability to drive. The risks and benefits of the procedure, including but not limited to bleeding, infection, loss of vision, loss of the eye, glaucoma, retinal detachment, corneal edema, macular edema, dropped nucleus, dropped intraocular lens, vitreous prolapse, capsular tear, capsular dialysis, need for glasses after surgery, need for further surgery were discussed and the patient wished to proceed.
DESCRIPTION OF PROCEDURE: After arriving in the operating room, a time out identified the patient and that the correct operative eye was the right eye. A subconjunctival block consisting of 0.4 cc of 2% Xylocaine with epinephrine was placed temporally around the right eye. The right eye was then prepped and draped in the usual sterile fashion and a lid speculum inserted. A superotemporal side
port incision was made with a Supersharp blade, and Provisc was instilled into the anterior chamber. A 2.8 mm diamond blade was used to make a temporal clear corneal wound. An anterior capsular tear and flap was initiated using the cystotome, and a curvilinear capsulorrhexis was completed
using Utrata forceps. Good hydrodissection and hydrodelineation of the lens nucleus was performed using
balanced salt solution and a blunt cannula. The lens nuclear material was then phacoemulsified using a vertical chop technique. Residual cortical material was removed using the irrigation aspiration apparatus. Provisc was instilled into the capsular bag and a 17.0 diopter, Model SN60WF intraocular lens, Serial No. 12413431009 was inserted into the capsular bag using the Injector system. Residual Viscoelastic was removed using the irrigation aspiration apparatus and the clear corneal wounds were stromally hydrated. The anterior chamber was noted to be well formed to a good palpable pressure. The intraocular lens was
well centered in the capsular bag and the clear corneal wounds were noted not to leak.
0.5 cc of 0.1% moxifloxacin was injected into the anterior chamber, under the iris, and into the bag.
A drop of TobraDex was placed in the eye prior to patching with a Fox shield.
COMPLICATIONS: None
PREOPERATIVE DIAGNOSIS:
Cataract, Right eye
POSTOPERATIVE DIAGNOSIS:
Cataract, Right eye
FINDINGS: Cataract, Right eye
PROCEDURE: Phacoemulsification posterior chamber intraocular
lens implant, Right eye.
ANESTHESIA: Subconjunctival block
INDICATIONS: This patient with a visually significant cataract in the right eye interfering with the
ability to drive. The risks and benefits of the procedure, including but not limited to bleeding, infection, loss of vision, loss of the eye, glaucoma, retinal detachment, corneal edema, macular edema, dropped nucleus, dropped intraocular lens, vitreous prolapse, capsular tear, capsular dialysis, need for glasses after surgery, need for further surgery were discussed and the patient wished to proceed.
DESCRIPTION OF PROCEDURE: After arriving in the operating room, a time out identified the patient and that the correct operative eye was the right eye. A subconjunctival block consisting of 0.4 cc of 2% Xylocaine with epinephrine was placed temporally around the right eye. The right eye was then prepped and draped in the usual sterile fashion and a lid speculum inserted. A superotemporal side
port incision was made with a Supersharp blade, and Provisc was instilled into the anterior chamber. A 2.8 mm diamond blade was used to make a temporal clear corneal wound. An anterior capsular tear and flap was initiated using the cystotome, and a curvilinear capsulorrhexis was completed
using Utrata forceps. Good hydrodissection and hydrodelineation of the lens nucleus was performed using
balanced salt solution and a blunt cannula. The lens nuclear material was then phacoemulsified using a vertical chop technique. Residual cortical material was removed using the irrigation aspiration apparatus. Provisc was instilled into the capsular bag and a 17.0 diopter, Model SN60WF intraocular lens, Serial No. 12413431009 was inserted into the capsular bag using the Injector system. Residual Viscoelastic was removed using the irrigation aspiration apparatus and the clear corneal wounds were stromally hydrated. The anterior chamber was noted to be well formed to a good palpable pressure. The intraocular lens was
well centered in the capsular bag and the clear corneal wounds were noted not to leak.
0.5 cc of 0.1% moxifloxacin was injected into the anterior chamber, under the iris, and into the bag.
A drop of TobraDex was placed in the eye prior to patching with a Fox shield.
COMPLICATIONS: None