I have a surgeon that performed bilateral ectropion repair and also bilateral punctoplasty with stent placement.
I coded 67914 for the ectropion repair, but I am questioning what to report for the punctoplasty with stent placement? He states that the stents were passed through the inferior puncata and down into the canaliculus. Does this supports 68815, even though he is calling the procedure a "punctoplasty". Please see OP report below. Any advise would be greatly appreciated.
PROCEDURE: The patient was brought to the operating room and prepped and draped in a sterile fashion. He was then given a lower lid block consisting of a total of 5 mL of 2% Xylocaine with epinephrine. The puncta were dilated, and a snip punctoplasty was performed of the punctal sphincter. At this point, the Mini-Minoka monocanalicular stents were trimmed and brought into position and passed through the inferior puncta down into the canaliculus. This was then seated within the punctum and sutured in place bilaterally with 6-0 silk suture. Good position was obtained of these stents. At this point, a lateral canthotomy and cantholysis was performed bilaterally, and the lateral tarsus was sutured to the medial portion of the lateral orbital rim and tied securely with a 4-0 Prolene suture. The lateral canthus was reformed with 1 interrupted 6-0 chromic suture. Erythromycin ointment was placed on the incision. The patient tolerated the procedure well.
I coded 67914 for the ectropion repair, but I am questioning what to report for the punctoplasty with stent placement? He states that the stents were passed through the inferior puncata and down into the canaliculus. Does this supports 68815, even though he is calling the procedure a "punctoplasty". Please see OP report below. Any advise would be greatly appreciated.
PROCEDURE: The patient was brought to the operating room and prepped and draped in a sterile fashion. He was then given a lower lid block consisting of a total of 5 mL of 2% Xylocaine with epinephrine. The puncta were dilated, and a snip punctoplasty was performed of the punctal sphincter. At this point, the Mini-Minoka monocanalicular stents were trimmed and brought into position and passed through the inferior puncta down into the canaliculus. This was then seated within the punctum and sutured in place bilaterally with 6-0 silk suture. Good position was obtained of these stents. At this point, a lateral canthotomy and cantholysis was performed bilaterally, and the lateral tarsus was sutured to the medial portion of the lateral orbital rim and tied securely with a 4-0 Prolene suture. The lateral canthus was reformed with 1 interrupted 6-0 chromic suture. Erythromycin ointment was placed on the incision. The patient tolerated the procedure well.