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Help coding op report please

  1. #1
    Default Help coding op report please
    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. Default
    I'm going to say 67108, 66984-51 because you did the lens placement and repaired the retina via vitrectomy.

  3. Smile
    I think 67040 & 66984 should be correct here.

  4. #4
    Default Bundled
    Quote Originally Posted by ewinnacott View Post
    I'm going to say 67108, 66984-51 because you did the lens placement and repaired the retina via vitrectomy.
    67108 and 66984 is bundled so if this would be the appropriate code then you can only bill 67108.

  5. #5
    Quote Originally Posted by ksandeep View Post
    I think 67040 & 66984 should be correct here.
    I agree, i keep going over the op report and still feel confident in 67040 and 66984-51, now the more i read i think of 67042 but that seems a little too in dept and i don't think there is enough documentation to use that code. But any suggestions would be appreciated. Thanks

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