code 67041 or 67042????

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296
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Pensacola, FL
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I'm leaning toward 67042, but wanted 2nd, 3rd, or even 4th opinions??? :)


The patient was identified in the preoperative holding area at which time her right eye was identified as the correct operative eye. This was re-verified in the operating room. Following this, the patient's right eye was prepped and draped in the appropriate sterile fashion for intraocular surgery. After retrobulbar injection was performed, the lid speculum was placed. A #25 gauge trocar entry was made. The BIOM was used for posterior visualization. Central core vitrectomy followed by peripheral vitrectomy was performed assisted by Kenalog staining. Kenalog was also stained the surface of the macular pucker. A barbed #25-gauge MVR blade was used to make an incision in the pucker and the pucker was peeled with ILM forceps. ICG was used to stain the ILM. This was stained very well with a brilliant green. The barbed MVR blade was then used to remove the ILM completely as well. Fluid-air exchange was then performed once the retina was visualized as being completely attached. The trocars were removed and the patient's eye was patched and shielded appropriately.

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