??? if Vitrectomy should be billed
Could someone please review this op report to see if I should bill the vitrectomy?? I think I am confusing myself on this one because it seems as it was performed but uncertain what cpt code I should use... I have chosen 66984 for the cataract extraction.... ANy help is grealty appreciated thank you
POSTOPERATIVE DIAGNOSIS: Advanced cataracts of the left eye.
OPERATION PERFORMED: Cataract extraction of the left with
implantation of anterior chamber intraocular lens implant.
COMPLICATIONS: Posterior capsular rupture with vitreous loss.
PROCEDURE: The patient was brought into the operative room. She was
prepped and draped as usual with 0.5% Betadine solution. Following
this, I proceeded to enter the anterior chamber to clear cornea.
This was in the 5 o'clock position and then following this, I did
notice that the pupil was 4 mm in size and so we inject into the
anterior chamber after making a port of entrance at the 12 o'clock
position and the other incision with a 2.4 keratome. This was
located about 15 degrees.
Following this, after injecting _______into the anterior chamber, the
pupil remained the same size. There was no dilation at all so then
we proceeded to push/pull after injection Healon GV into the anterior
chamber. Actually, we did Viscoat on this anterior chamber to
protect the iris and the cornea because the cornea has epithelial
corneal dystrophy, very delicate and it makes it difficult to see
inside the eye to do the surgery. We accomplished with the push/pull
technique to enlarge the pupil up to 5.5 mm and then we did a
capsulorrhexis 360 degrees without difficulty after placing Viscoat
into the anterior chamber.
Following this, I did proceed to rotate the nucleus and remove this
by phacoemulsification by the divide and conquer technique. Then, we
removed the cortical material out of the eye and pieces of nucleus we
tried to remove. We noticed at this time that the anterior chamber
became deeper so then we knew that there was a rupture of the
posterior capsule with vitreous in anterior chamber. So we proceeded
to do a vitrectomy of this eye and injected Healon GV and also
Viscoat into the posterior chamber, and then we noticed that there
were fragments of the nucleus coming in the surface so we could
remove with the vitrectomy machine. We removed this and then looked
carefully and there were no more pieces of the nucleus so we
proceeded to enlarge the wound. We placed Miochol into the anterior
pupil but since the patient has stretching with the Cook lens, the
pupil was irregular and did not close well. We did aspirate all of
the material as we could and there appeared to be a very clean
posterior pole. Following this, I did proceed to put Miochol into the
anterior chamber and then enlarge the wound up to 5.5 mm in size and
then introduce the lens implant into the anterior chamber in front of
the iris and then we placed four sutures of 10-0 nylon to approximate
the edges of the wound and I did pressurize the eye. There was no
leakage. The patient bled slightly inferiorly and perhaps from the
edge of the iris with a push/pull which maybe was compromised
Following this, I did notice that the lens implant was in good
position; however, the iris was not strong enough to hold well this
lens but that is the only choice that we have with this one.
Following this, we proceeded to remove the Healon and Viscoat from
the anterior chamber but from the posterior chamber we could not do.
We did place one drop of Timolol into the eye and one drop of Pred
Forte and one drop of Vigamox into the eye. We removed the eyelid
speculum as well as the draping and placed an eye shield to protect