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Help in coding op report

  1. Default Help in coding op report
    Medical Coding Books
    Hello fellow coders,
    Looking for your opinion , any and all will be so appreciated.
    Preoperative DX: Recurrent pteryguim, right eye
    Post operative DX: same
    Operative Procedure: Conjuntival reconstruction
    Sub-Tenon's injection, right eye

    Following the administration of local anesthesia, the patient was prepped and draped in the usual sterile opthalamic fashion. Next, 2 6-0 Vicryl sutures were placed at the limbus, 1 inferiorly and 1 superiorly, and used to rotate the eye temporally to expose the pterygium nasally. This was removed using a combination of blunt and sharp dissection, and the cornea was polished to remove the remaing tissue. Hemostasis was obtained. Mytomycin-C in a concentrate of 0.04% was palced on the conjunctiva for 2 minutes and then the eye was irrigated copiously. A pedicle graft was taken from the conjuntiva superiorly and swung to cover the conjunctival defect completely. This was secured in place suing a running 8-0 Vicryl suture. Kenalog was injected in a sub-tenon's fashion. The graft was noted to cover the defect completely. A bandaage contact lens was applied and Maxitrol ointment instilled. The eye was patched and shielded. The patient tolerated the procedure well and left the room clean and in good condition.

    I coded this as 65426. The physician coded this 65782. I would appreciate any and all opinions in this . I do also plan to query the physician .

  2. Default 65782 is correct
    the 65400 states excision of lesion, cornea..except the pterygium which is an incorrect code. The 65782 is more appropriate to use and includes obtaining the graft.

  3. #3
    You are correct 65426 describes the surgery performed. The code selected by the physician 65782 is ocular surface reconstruction limbal conjunctival autograft. Coders Desk reference states this is done for corneal defects or damage due to loss of stem cell function. It also indicates that the graft is taken from the other eye. 65782 is a much more detailed operation then the one described in the OP report.

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