Wiki Cataract Surgery


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The surgeon performed the following procedure in an ASC:

Following light intravenous sedation, local anesthetic tetracaine eye drops were placed in the eye, and the patient was prepped and draped in the usual sterile fashion for cataract surgery. An LRI was performed at the appropriate axis. A paracentesis was made, and the anterior chamber reformed with 1% preservative-free lidocaine, which was then washed out with DuoVisc. A 3mm clear corneal temporal incision was made and the 360-degree circular tear capsulotomy, followed by hydrodissection of the nucleus and removal of the nucleus from the posterior chamber using a chopping technique. Remaining cortex was aspirated from the eye, and the posterior capsule was lightly polished. ProVisc was used to reform the posterior capsular bag, and a posterior chamber intraocular lens manufactured by Alcon, model SN60T5, of 14.0 diopter was injected through the incision and unfolded in the capsular bag. Remaining ProVisc was aspirated from the eye, and the anterior chamber was reformed with dilute Miostat. The incision was tested and found to be watertight. Tobrodex drops were place over the eye followed by a light pressure patch and shield. The patient left the operating room having tolerated the procedure well.

DX: Complex Cataract

Please give me opinions on coding for both the surger and the DX.
Thanks for you input, Mary. Regarding the Limbal Relaxing Incision, is that always part of a cataract surgery? I know that an incision can be made at the limbus (corneal scleral juncture) during cataract surgery, but is that the same as an LRI? There is a code for Corneal Relaxing Incision which is used specificially for correction of a surgically induced astigmatism. The problem is that whenever the surgeon states he did an LRI there is a question as to why it was done.
I code multiple Cataract surgeries a day and they all have that incision so yes would be the answer to your question. 66984 would be the proper code for what is described in the dictation. Complex removal is much more involved than the info that you have indicated that your phy is giving you.
Thanks for your response. When you say "they all have that incision" are you referring to an incision at the limbus (corneo-scleral juncture) or a corneal relaxing incision as in 65772? I seen dozens of cataract reports where this incision is not mentioned at all--or perhaps the surgeon uses different terminology for the same incision.