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Cataract extraction w/lensectomy & pars plana vitrectomy

coderguy1939

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Prior to surgery, the doctor discussed with the patient that there might be some compromise to the posterior capsule and that vitrectomy and lensectomy might be necessary. During phaco the lens nucleus migrated posteriorly. The doctor finished the phaco, then performed phaco-fragmentation of the lens nucleus (66850) and a pars plana vitrectomy (67036). Since this was discussed with the patient preoperatively, can all of these procedures be coded together?
 

mbort

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If the prolasped vitreous exists and is known in advance (documented in the patients medical record) it is not considered a complication of the cataract surgery. Therefore the physican who plans to perform a vitrectomy during the same operative session of cataract surgery could separately code for the vitrectomy using the 59 modiifer.
 

coderguy1939

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There was no prolapsed vitreous documented preoperatively, just a suspicion that there might be some "posterior capsular compromise" which was discussed with the patient along with the possibility of the additional procedures. What the doctor suspected occurred during surgery. Can the lensectomy and vitrectomy be coded? What the doctor suspected seems to be something that may occur during any cataract surgery.
 

mbort

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I would say yes simply because he did anticipate (suspect) the possibility of the additional procedure prior to surgery and its documented.
 
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