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Retained Lens Fragment

  1. #1
    Default Retained Lens Fragment
    Medical Coding Books
    Post Op: Retained lens fragment, left eye

    Procedure: Removal of the retained lens fragment, left eye

    After the patient was seen and identified in the preop holding area, the left eye was marked for left monocular surgery. The patient was taken to operating room and placed on the table in the supine position. Topical lidocaine jelly and antibiotic had been placed on the eye. The patient's left eye was then carefully prepped and draped in the usual fashion. The lid speculum was then placed on the left eye. A superior paracentesis was made using side port blade. Viscoelastic was then placed into the eye through hold the lens fragment inferiorly, where it had been stable for several weeks. An additional paracentesis was made inferiorly. Then using bimanual irrigation-aspiration hadpieces, the viscoelastic was removed from the eye and the nuclear piece was easily aspirated from the anterior chamber. The anterior chamber was then inflated with viscoelastic to normal pressure. The wounds were checked and found to be watertight. The anterior chamber was deep. The patient tolerated the procedure well and was taken to the recovery in stable condition.

    I need some input as to what code would be correct. 66840 is for aspiration, but only a fragment was removed so I was looking at 65235. Any help is greatly appreciated!!

  2. #2
    If this was f/u for cataract surgery, the doctor may be aspirating cataract fragments (998.82) in which case we're not talking about a foreign body. I'd clarify it with the doctor.

  3. Default
    Wouldn't this be 66852; removal of lens material; pas plana approach, with or without vitrectomy. This codes describes the removal of a cataract during retinal surgery or to remove a piece of natural lens retained following cataract surgery.

  4. #4
    Default removal cataract fragments
    I think the CPT code selection should be based on approach. If the material were removed via anterior approach and aspiration was the method, 66840 should be the proper code.

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