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Tear during Cataract surgery

  1. Question Tear during Cataract surgery
    Medical Coding Books
    I was wondering how to code this complication from a dx stand point.

    After the implant was placed there was some residual cortical material that was being removed there was noted to be a small tear in the posterior capsule with some vitreaous present: therefore a limited anterior vitrectomy was undertaken in a binmanual techniqu through a self sealing paracentesis site............

    I was going to use dx 366.16, 871.1, and E870.0 Any thought on this????

    Thank you for all your time in advance!
    Kelly Sumansky, MA, CPC-H, CMC

  2. #2
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    Quote Originally Posted by Ksumansky View Post
    I was wondering how to code this complication from a dx stand point.

    After the implant was placed there was some residual cortical material that was being removed there was noted to be a small tear in the posterior capsule with some vitreaous present: therefore a limited anterior vitrectomy was undertaken in a binmanual techniqu through a self sealing paracentesis site............

    I was going to use dx 366.16, 871.1, and E870.0 Any thought on this????

    Thank you for all your time in advance!
    I would not use the e-code as it pertains to an actual "cut" that would have been caused by the srugeon. The surgeon is calling it a tear.

    Make sense?
    Mary, CPC, COSC

  3. Default
    so I wouldn't use the e code but I would keep the 871.1? Or did I pick the wrong E code? Would E878.8 work better in your opinion?

    Thank you for your advice.

    Kelly
    Kelly Sumansky, MA, CPC-H, CMC

  4. #4
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    I would check with the surgeon, It sounds to me more like there was some vitreous prolapse from the tear.

    I would not use the 871.1, that is for a laceration (unless you have documentation that actually states "laceration")


    The E848.8 could be okay, but before doing that I would check with the surgeon regarding the above.

    Hope this helps
    Mary, CPC, COSC

  5. #5
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    Albany, New York
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    If your physician confirms that this "tear" was a result of the procedure, you could use 998.2 with E870.0
    Karen Maloney, CPC
    Data Quality Specialist

  6. Default
    I would agree w/ Karen

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