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67800-e2?? First time seeing this

  1. #1
    Default 67800-e2?? First time seeing this
    Medical Coding Books
    SURGICAL SERVICE: Ophthalmology


    PREOPERATIVE DIAGNOSIS(ES):
    1. Chalazion, Left lower eyelid.


    POSTOPERATIVE DIAGNOSIS(ES):
    1. Chalazion, Left lower eyelid.


    PROCEDURE(S) PERFORMED:
    1. Incision and curettage of Left lower eyelid chalazion.


    SURGEON:
    ANESTHESIA:General anesthesia
    ANESTHESIOLOGIST:
    ESTIMATED BLOOD LOSS: <1 mL


    COMPLICATIONS: None


    DISCHARGE CONDITION: Stable




    SURGICAL TECHNIQUE: The patient was brought to preoperative holding area, was transferred to the operating room. and was placed in the supine position. General anesthesia was induced without difficulty. 1.00 mL of the above-mentioned local anesthetic mixture was infiltrated into the Left lower eyelid. The Left eye was prepped and draped in a sterile fashion for oculoplastic surgery
    Attention directed to the Left lower lid, where a chalazion clamp was applied and the lid was everted. A #11 blade was used to create a vertical incision through the tarsal plate into the chalazion. The lipogranulomatous contents of the chalazion were removed with a curettte. Bipolar cautery was applied judiciously for hemostasis. The chalazion clamp was removed and the eyelid de-everted. The drapes were removed. The face was cleaned.


    Maxitrol ophthalmic ointment applied to the Left eye, which was dressed with a light pressure patch. The patient tolerated the procedure well without complication, was extubated, and was brought to the recovery room in stable condition. The patient will follow up with Dr. XX at 2 weeks postop and will be contacted by telephone at 1 day postop.

  2. #2
    Location
    Columbia, MO
    Posts
    12,910
    Default
    What are you questioning on this. It looks correct to me.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    Thanks, the coder that does the professional piece coded 67850, but I coded 67800, so just wanted another opinion. Thanks!
    Melissa Bedford,CCS,CPC

  4. #4
    Location
    Columbia, MO
    Posts
    12,910
    Default
    I think clearly it was a removal of the chalazion as opposed to a destruction. The note clearly states the contents were removed.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Smile
    I agree with Debra. The note is cut and dry.
    [COLOR="Blue"]Kandy Morris CCS, CCS-P, CPC, CPB, CPC-I, CPMA, CEMC, CPOC
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