AlaskanCoder
Guru
Can anyone help me code this? The preop dx was "presumed vitreous hemorrhage with retinal detachment" and the postop dx was "fungal endophthalmitis".
The surgeon wrote:
"Because the eye was presumed to have a retinal detachment based on the history and preoperative ultrasound exam, the conjunctiva was opened for 360 degrees. The 3-0 silk traction sutures were placed beneath each rectus muscle. A 240 band was placed about the eye. The ends of the band are joined beneath the medial rectus muscle. The band was anchored to the sclera in each quadrant with a single Supramid mattress suture. The 25-gauge cannulas were then inserted at 8. 9:30 and 2 o'clock. With the benefit of intraocular illumination and the opertating microscope, it was possible to see that the vitreous was very hazy and contained multiple light clots of dense material suggestive of a Candida endophthalmitis. The vitreous culture was sent to the laboratory for a Gram stain that confirmed the presence of an organism consistent with Candida endophthalmitis. The vitrectomy was completed as fully as possible. No retinal detachment was observed. A possible area of localized retinitis was observed near 6 o'clock in the far periphery. The intraocular pressure was reduced. The 25-guage cannulas were withdrawn. The sclerotomies were closed with 8-0 Vicryl sutures. The operative field was copiously irrigated with balanced salt solution and Ancef. 10 mcg of amphotericin was injected slowly into the mid vitreous cavity with a 30-guage needle introduced through the pas plana at 11 o'clock. Conjunctiva and tenon's capsule were closed with several interrupted 8-0 Vicryl sutures. Ancef was injected subconjunctivally. Maxitrol ointment and an eye patch were applied to the eye. "
The surgeon documented the name of the procedure as "Vitrectomy, scleral buckle, vitreous cultures, and intraocular amphotericin injection, right eye."
He selected CPT code 67108-RT with ICD-9-CM 360.01
Since there was no repair of a retinal detachment, I do not feel this is the correct code. However, he did do a scleral buckle, but the only codes include repair of retinal detachment.
Would it be appropriate to code 67108-52-RT? Or is there an applicable code?
Thank you for your help!
Karen Hill, CPC, CPMA
The surgeon wrote:
"Because the eye was presumed to have a retinal detachment based on the history and preoperative ultrasound exam, the conjunctiva was opened for 360 degrees. The 3-0 silk traction sutures were placed beneath each rectus muscle. A 240 band was placed about the eye. The ends of the band are joined beneath the medial rectus muscle. The band was anchored to the sclera in each quadrant with a single Supramid mattress suture. The 25-gauge cannulas were then inserted at 8. 9:30 and 2 o'clock. With the benefit of intraocular illumination and the opertating microscope, it was possible to see that the vitreous was very hazy and contained multiple light clots of dense material suggestive of a Candida endophthalmitis. The vitreous culture was sent to the laboratory for a Gram stain that confirmed the presence of an organism consistent with Candida endophthalmitis. The vitrectomy was completed as fully as possible. No retinal detachment was observed. A possible area of localized retinitis was observed near 6 o'clock in the far periphery. The intraocular pressure was reduced. The 25-guage cannulas were withdrawn. The sclerotomies were closed with 8-0 Vicryl sutures. The operative field was copiously irrigated with balanced salt solution and Ancef. 10 mcg of amphotericin was injected slowly into the mid vitreous cavity with a 30-guage needle introduced through the pas plana at 11 o'clock. Conjunctiva and tenon's capsule were closed with several interrupted 8-0 Vicryl sutures. Ancef was injected subconjunctivally. Maxitrol ointment and an eye patch were applied to the eye. "
The surgeon documented the name of the procedure as "Vitrectomy, scleral buckle, vitreous cultures, and intraocular amphotericin injection, right eye."
He selected CPT code 67108-RT with ICD-9-CM 360.01
Since there was no repair of a retinal detachment, I do not feel this is the correct code. However, he did do a scleral buckle, but the only codes include repair of retinal detachment.
Would it be appropriate to code 67108-52-RT? Or is there an applicable code?
Thank you for your help!
Karen Hill, CPC, CPMA