Do I use an unlisted code for this?

Ft. Myers, Florida
Best answers
I need a bit of help on a case that I am working. My concern is that I will have to use the unlisted code 66999, and I cannot locate a ‘like' code for it. I have been looking at 66250 to use as a ‘like' code, but would appreciate input before sending claim. Many thanks in advance.

Pre-op diagnosis: 1. Traumatic injury, left eye
2. Rule out corneal sclera laceration, wound dehiscence or lens dislocation.

Post-op diagnosis: Same

Operation performed: Examination under anesthesia with operating microscope

Description of procedure: The patient was brought to the operating room and placed in the supine position on the operating table. A topical anesthetic was administered to the left eye. The anesthetic was a 50-50 mixture of 2% Xylocaine and 0.75% Marcaine. Using the operating microscope the eye was gently examined. A blepharostat was placed. There was a large subconjunctival hemorrhage. Medially there was an elevated which appeared to be an elevation of the episclera. The conjunctiva was intact for 360 degrees. The cornea had an abrasion, but was otherwise clear. The previous cataract wound was secure. This was tested with fluorescein strip using Seidel test. The lens implant appeared to be well-centered in its appropriate position. Tactile tension revealed the globe to be firm. At this point it was felt that there was no wound dehiscence or corneal sclera laceration and no further treatment was indicated. The patient was taken to the recovery room in stable condition having suffering no complications.

H&P (on additional note, not attached to op report): This is a 68-year-old who presented to the surgery center after being struck in left eye by a tree branch. Patient is aprox. one month status post cataract extraction and lens implant surgery in both eyes. Was concerned about possible penetrating injury and came directly to surgical center.