I have an op report that I would like some opinions on how I have coded
Post operative DX: Complex cataract, left eye
Following the administration of topical anesthesia, the patient was prepped and draped in the usual sterile ophthamic fashion. A paracentesis was made. The anterior chamber was entered through the cornea temporally, using a keratome. The anterior was was inflated with viscoelastic. A Kuglen hook was used to stretch the pupil to to achieve a diameter of roughly 6mm. A capsulorrhexis was perfomed. Hydrodissection was performed. Phacoemulsification was performed. Irrigation and aspiration was performed. The capsular bas was inflatedwith viscoelastic. The inraocular lens in Alcon SN60WF 22.0 diopter was injectedinto the capsular bag. The remaining voscoelastic was removed. The wound was inspected and found to be watertight. The inraocular lens was instected and found to be well centered. The eyelid speculum was removed. The eye was shielded. The patient tolerated procedure well and left the room clean and in good condition..
I coded 336.9 an additional code to support , in the instance being that Dr used the Kuglen hooks, I used 379.40. Is this rationale correct? My reason for questioning is that some of my charts have been sent to an outside company for audit and they coded this as 366.30
I would like opinions on this.
Thank you
Paula
Post operative DX: Complex cataract, left eye
Following the administration of topical anesthesia, the patient was prepped and draped in the usual sterile ophthamic fashion. A paracentesis was made. The anterior chamber was entered through the cornea temporally, using a keratome. The anterior was was inflated with viscoelastic. A Kuglen hook was used to stretch the pupil to to achieve a diameter of roughly 6mm. A capsulorrhexis was perfomed. Hydrodissection was performed. Phacoemulsification was performed. Irrigation and aspiration was performed. The capsular bas was inflatedwith viscoelastic. The inraocular lens in Alcon SN60WF 22.0 diopter was injectedinto the capsular bag. The remaining voscoelastic was removed. The wound was inspected and found to be watertight. The inraocular lens was instected and found to be well centered. The eyelid speculum was removed. The eye was shielded. The patient tolerated procedure well and left the room clean and in good condition..
I coded 336.9 an additional code to support , in the instance being that Dr used the Kuglen hooks, I used 379.40. Is this rationale correct? My reason for questioning is that some of my charts have been sent to an outside company for audit and they coded this as 366.30
I would like opinions on this.
Thank you
Paula