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Can someone please help coding this op report

  1. #1
    Default Can someone please help coding this op report
    Medical Coding Books
    Operations: A 23-gauge pars plana vitrectomy/membrane peel/endolaser.
    Cataract extraction with intraocular lens placement.

    Procedure was begun with the creation of three sclerotommies each 3.5 mm from the limbus as measured with calipers. Newt some anterior vitrectomy was performed in order to decrease posterior pressure. During this anterior vitrectomy a rent in the posterior capsule was created. Next attention was turned to the anterior segment and a paracenteses incision was made through which viscoelastic was used to fill the anterior chamber. Next a keratome blade was used to create a triplanar clear corneal incision and a cystome and utrata forceps were used to create a continuous curvilinear capsulorrhexis. A temporal section of the continuous curvilinear capsulorrhexis did extend to connect to the rent in the posterior capsule. The nucleus was found to have gone through this rent into the posterior pole. The remaining cortical material was aspirated. It was noted that over 300 degrees of the anterior capsular shelf still remain. Next attention was turned back to the posterior pole and core vitrectomy was performed. All vitreous hemorrhage was cleared until I got the view of the remaining posterior pole. With the clearing of the vitreous hemorrhage we were able to see the nucleus which had swollen on to the retina as well as the large tractional retinal detachment. Next the nucleus was removed via the fragments. Then we identified the posterior outlet piece and induced a posterior vitreous attachment of the optic nerve. Forceps and micro incision scissors were used to remove the tractional bands which are responsible for the retinal detachment. Much of these trational membranes were able to be removed with minimal damage to the underlying retina. A small iatrogenic ring was noted to which a endolaser was performed. A 360 degree scleral depressed vitrectomy was then performed. Retina was noted to be flattened. Vitrectomy instruments were removed and each of the sclerotomies were sutured. Then a repeat intraocular lens was placed in the the sulcus. The temporal corneal would were closed.

    I came up with 66984 and 67040. Co worker came up with 67108.

  2. #2
    I would use the 66984 and 67040. I feel this best describes what was performed. Hope this helps.

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