HELP!! Removal and cautery of corneal vessels

michiboo

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Well this one got me, can't find a specific code. Has anyone ran into something similar and what code did you apply....



PREOPERATIVE DIAGNOSIS: Pre-Op Diagnosis Codes:
   * Vernal conjunctivitis [H10.44]
   * Keratitis [H16.9]
POSTOPERATIVE DIAGNOSIS: Post-Op Diagnosis Codes:
   * Vernal conjunctivitis [H10.44]
   * Keratitis [H16.9]

PROCEDURE/SURGERY: Removal and cautery of corneal vessels

SURGEON: Surgeon(s):
XXXXX

ANESTHESIOLOGIST: XXXXX
ANESTHESIA TYPE: General

Description of procedure:
After proper consent was obtained.atient was brought to the recovery room where the affected eye was prepped and draped in the usual sterile fashion. TGeneral anesthesia was attained by Dr Nguyen. An eyelid speculum was placed. Topical anesthetic was applied to the patient's eye. The corneal surface down to Bowmans layer was then gently scraped using a Tooke knife and Colibri forceps in the area of the blood vessel leading into the central cornea from the superior limbus.Limbal vessels leading into the cornea were cauterized superiorly.  A retrobulbar injection was administered. A 50/50 mixture of 1% Lidocaine/0.75% Marcaine was given into the retrobulbar space. A total of 3 cc's was injected. Topical antibiotic and anti-inflammatory were then applied. The patient's eye was patched with tobradex ointment. The patient tolerated the procedure well and there were no complications.
 

fwnewbie

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EEsh! I'm very, very new at this, but I have lots of surgical experience with eyes and my guess is 65435 for the scraping, and 65450 for the cautery destruction of the lesion (blood vessels). Good luck!
 

Cheezum51

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First of all, the diagnoses you have in these notes don't really go along with the procedure. I would think that either corneal neovascularization (H16.40) or panes (H16.42) would be more appropriate. The procedure codes are probably those suggested by fwnewbie.

Tom Cheezum, O.D., CPC, COPC
 

Cheezum51

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The doctor should assign the diagnosis code since that decision involves medical decision making which the coder isn't licensed to do. I would approach the provider and ask them to consider adding the code for either of the two condition I suggested. They can be caused by the conditions the doctor has listed as diagnoses but I would be afraid that your claim wouldn't be paid without the addition of one of the codes I suggested or something similar.

Tom Cheezum, OD, CPC, COPC
 

michiboo

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appreciate all the feedback! thank you so much!

Definitely look into diagnosis, provider did document those diagnosis by the way but definitely will alert the provider.. :)
 
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