I'm still new at these opthalmology procedures and I'm confused. I work obviously at an ASC so I wanted to be sure that these codes were ok to use here and if I am missing something? Here is the op report:
POSTOPERATIVE DIAGNOSIS:
Aphakia, both eyes.
OPERATION:
1. Bilateral examination under anesthesia.
2. Biometry by ultrasound echo A-scan.
3. Biometry by ultrasound echo with power calculation.
ANESTHESIA:
General.
COMPLICATIONS:
None.
INDICATIONS:
The risks, benefits, and alternatives to an examination under anesthesia were discussed with the patient's mother and she elected to proceed.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room suite in stable condition and inducted under general anesthesia without complications. Both eyes were examined first with the slit-lamp.
The anterior segment showed clear and quite bulbar conjunctiva. The cornea was clear. The anterior chamber was deep and quite. The patient was aphakic OU. The posterior segment examination showed retinas to be flat 360 degrees bilaterally. Optic nerves were with sharp margins. There was no significant cuffing. A-scan readings for the right eye were as follows, 22.4, 20.35, 20.24, 20.25, 20.26, 20.27, 20.32, 20.31, 20.35, and 20.41. A-scan readings for the left eye were as follows, 20.57, 20.58, 20.63, 20.69, 20.67, 20.71, and 20.75. Keratometry readings for the right eye were as follows, 44.50/48.25, 42.75/48.37, 44.50/47.62, and 43.75/48.12. Keratometry readings for the left eye were as follows, 44.75/46.87, 44.62/44.87, 43.75/43.87, and 44.00/47.25. Applanation tonometry readings showed the pressures to be 10-15 mmHg, each eye.
I came up with:
92018
76516
76519
Am I even close? I guess I'm confused at the fact that these codes are in the Medicine section and Radiology part of the book and I know we are limited at ASC's for codes in these sections to use. It's a Medicaid patient.
Your help is much appreciated!!
POSTOPERATIVE DIAGNOSIS:
Aphakia, both eyes.
OPERATION:
1. Bilateral examination under anesthesia.
2. Biometry by ultrasound echo A-scan.
3. Biometry by ultrasound echo with power calculation.
ANESTHESIA:
General.
COMPLICATIONS:
None.
INDICATIONS:
The risks, benefits, and alternatives to an examination under anesthesia were discussed with the patient's mother and she elected to proceed.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room suite in stable condition and inducted under general anesthesia without complications. Both eyes were examined first with the slit-lamp.
The anterior segment showed clear and quite bulbar conjunctiva. The cornea was clear. The anterior chamber was deep and quite. The patient was aphakic OU. The posterior segment examination showed retinas to be flat 360 degrees bilaterally. Optic nerves were with sharp margins. There was no significant cuffing. A-scan readings for the right eye were as follows, 22.4, 20.35, 20.24, 20.25, 20.26, 20.27, 20.32, 20.31, 20.35, and 20.41. A-scan readings for the left eye were as follows, 20.57, 20.58, 20.63, 20.69, 20.67, 20.71, and 20.75. Keratometry readings for the right eye were as follows, 44.50/48.25, 42.75/48.37, 44.50/47.62, and 43.75/48.12. Keratometry readings for the left eye were as follows, 44.75/46.87, 44.62/44.87, 43.75/43.87, and 44.00/47.25. Applanation tonometry readings showed the pressures to be 10-15 mmHg, each eye.
I came up with:
92018
76516
76519
Am I even close? I guess I'm confused at the fact that these codes are in the Medicine section and Radiology part of the book and I know we are limited at ASC's for codes in these sections to use. It's a Medicaid patient.
Your help is much appreciated!!