Wiki Cyst on Medical Rectus Muscle

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AKEISTER

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Dr was performing a Medical rectus Recession, while exploring the muscle a cyst containing clear fluid was found at the superior edge of the indertion of the medial rectus muscle. the cyst was dissected and removed in total. The cyst did not rupture. It measured 7mm by 2mm. This was sent to pathology. I coded the recession as 67311 but not sure about the cyst... Any thoughts.

Thanks
Alice
 
coding cyst

That is an unusual scenerio. I would check the pathology report first to find out what kind of cyst it is, benign, malignant, etc.. then go to the CPT book. The surgeon is operating on a muscle of the eye. You might have to code the unlisted code, 67399. But, first check to see if there are any category III codes that can be coded. I personally would code the 67399 code if there is a complete description on the operative report to support it. If it is benign, I would use ICD-9 code, 224.8. You will find under the neoplasm table, muscle, extraocular. I coded surgeries for ophthalmology for 7 years and I have never seen this happen. I hope this helps.

Arlene Andrew, CPC, CPC-I
 
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