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Cataract Surgery Complications

  1. #1
    Default Cataract Surgery Complications
    Medical Coding Books
    Surgery being performed was Phacoemulsification w/IOL implant and Pars Plana Vitrectomy w/Endolaser.
    Pre & Post-op diagnoses were Cataract, vitreous hemorrhage secondary to proliferative diabetic retinopathy.

    The patient's iris protruded through the surgical incision and during insertion of the IOL "The iris became traumatized and portion was removed with Westcott scissors".

    The surgical report states "none" under complications.

    I'm looking at E870.0 but would appreciate input regarding the traumatized iris.


  2. #2
    procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)

    Thanks for the additional information. Under CCI Chapter 8 guidelines it states - "

    2. Iridectomy and/or anterior vitrectomy may be performed in conjunction with CATARACT extraction. If an iridectomy is performed in order to complete a CATARACT extraction, it is an integral part of the procedure and is not separately reportable. Similarly, the minimal vitreous loss occurring during routine CATARACT extraction does not represent a vitrectomy and is not separately reportable. If an iridectomy or vitrectomy that is separate and distinct from the CATARACT extraction is performed for an unrelated reason at the same patient encounter, the iridectomy and/or vitrectomy may be reported separately with an NCCI-associated modifier. The medical record must document the distinct medical necessity for each procedure.

  3. #3
    Hi David,

    I don't use the E codes unless the documentation specifically states that it was caused by the surgeon. To me, the documentation that you posted mearly suggested that it was a complication during the procedure and not an "accidental" cut into the iris.

    To me, and this is just my opinion, by using an E code, you are suggesting that it was caused by the surgeon.

    hope this helps
    Mary, CPC, CANPC, COSC

  4. #4
    Thumbs up
    I agree with mbort.

  5. #5
    Thanks, Mary and lgentry. Appreciate it.

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