I haven't been doing Ophthalmology that long, and I am not real familiar with reading op reports. I am practicing cataract surgeries, and here is an example of one. I would code it as 66982-RT with a dx code of 366.30, and I don't think this report supports using a modifier 59 for the vitrectomy, so could someone else give me their opinion on what they think. I'm struggling a little bit 
, so any advice would be greatly appreciated. Thank you!
Pre-op Dx: Traumatic Cataract right eye
POST-op Dx : Traumatic Cataract right eye
OPERATION PERFORMED: Phacoemulsification, intraocular lens implantation, vitrectomy, and synechialysis, right eye.
DESCRIPTION OF PROCEDURE: The patient was brought back to the operating room and prepped and draped in the usual sterile fashion for intraocular surgery. A lid speculum was inserted between the lids. A paracentesis tract was made. A clear corneal incision was also made. Viscoat was used to coat and protect the endothelium. It was noted to be a large plaque on the anterior capsule. There were peripheral anterior syrechiae. The synechiae were lysed using a Kuglen hook as well as the cannula from the Viscoat. The pupil would not dilate. Malyugin ring was implanted, A curvilinear capsulorrhexis was performed. Hydrodissection was then done. The nucleus was attempted to be rotated and were only rotate 90 degrees.
The nucleus was phacoemulsified in the posterior chamber using a divide and conquer technique. After one hemisection of the nucleus was removed, sutures prolapse out of the eye. Viscoat was used to try to levitate lens into the anterior chamber. A Kuglen hook was also used to atempt to move the nuclear fragment into the anterior chamber. The wound was enlarged. The nuclear fragment was very large. Using a lens loop, the lens was delivered from the eye. It was very difficult to remove the fragment as the fragment was bigger than the 6.20 Malyugin ring.
During the cataract removal, the Malyugin ring was delivered along with the cataract. The anterior vitrectomy was performed. It was noted to be no visible vitreous in the anterior chamber. Provisc was placed into the eye. An 18.5 diopter lens manufactured by Bausch & Lomb was placed in ciliary sulcus. Miostat was injected into the eye. A #10-0 nylon suture was used to close the incision. The wound was noted to be watertight causing contact lenses soaked in antibiotics, steroids, and NSAIDs were placed on the eye lid with steroid along semi-pressure patch and fox shield.
, so any advice would be greatly appreciated. Thank you! Pre-op Dx: Traumatic Cataract right eye
POST-op Dx : Traumatic Cataract right eye
OPERATION PERFORMED: Phacoemulsification, intraocular lens implantation, vitrectomy, and synechialysis, right eye.
DESCRIPTION OF PROCEDURE: The patient was brought back to the operating room and prepped and draped in the usual sterile fashion for intraocular surgery. A lid speculum was inserted between the lids. A paracentesis tract was made. A clear corneal incision was also made. Viscoat was used to coat and protect the endothelium. It was noted to be a large plaque on the anterior capsule. There were peripheral anterior syrechiae. The synechiae were lysed using a Kuglen hook as well as the cannula from the Viscoat. The pupil would not dilate. Malyugin ring was implanted, A curvilinear capsulorrhexis was performed. Hydrodissection was then done. The nucleus was attempted to be rotated and were only rotate 90 degrees.
The nucleus was phacoemulsified in the posterior chamber using a divide and conquer technique. After one hemisection of the nucleus was removed, sutures prolapse out of the eye. Viscoat was used to try to levitate lens into the anterior chamber. A Kuglen hook was also used to atempt to move the nuclear fragment into the anterior chamber. The wound was enlarged. The nuclear fragment was very large. Using a lens loop, the lens was delivered from the eye. It was very difficult to remove the fragment as the fragment was bigger than the 6.20 Malyugin ring.
During the cataract removal, the Malyugin ring was delivered along with the cataract. The anterior vitrectomy was performed. It was noted to be no visible vitreous in the anterior chamber. Provisc was placed into the eye. An 18.5 diopter lens manufactured by Bausch & Lomb was placed in ciliary sulcus. Miostat was injected into the eye. A #10-0 nylon suture was used to close the incision. The wound was noted to be watertight causing contact lenses soaked in antibiotics, steroids, and NSAIDs were placed on the eye lid with steroid along semi-pressure patch and fox shield.