I am wondering if someone can take a look at this op report, I am not sure if I should code it 66984-52 or 66850 or if there is another code ??????


PREOPERATIVE DIAGNOSES:
1. Brunescent cataract of the right eye in a patient with extremely
high myopia and history of macular degeneration.
2. Astigmatism of the right eye.

POSTOPERATIVE DIAGNOSES:
1. Brunescent cataract of the right eye in a patient with extremely
high myopia and history of macular degeneration.
2. Astigmatism of the right eye.

PROCEDURE:
1. Cataract extraction of the right eye by phacoemulsification. 2.
Limbal relaxing incisions.

COMPLICATIONS: None.

ANESTHESIA: Monitored anesthesia care (MAC).

DESCRIPTION OF THE PROCEDURE: The patient was brought into the
operating room. He was prepped and draped as usual with 0.5%
Betadine solution. Prior to this, the patient had tetracaine eye
drops every five minutes x4 and one drop of Marcaine 0.75%. After
the patient as prepped with 0.5% Betadine solution, I placed a
self-retaining eyelid speculum to separate the eyelids. Then, I
entered the anterior chamber at clear cornea temporally with a 2.1
keratome. I did port of entrance also at 1-mm opening at clear
cornea of the limbal area. This was at _______ o'clock position.
Following this, I did inject into the anterior chamber 1% lidocaine
preservative-free and filled the anterior chamber with Healon GV.
Following this, I did proceed to do capsulorrhexis 360 degrees and
then I removed this portion of the capsule and there was intact
posterior capsule.

Because of the high myopia, there was no need to do a lens implant in
this patient's right eye.

Following this, a drop of Vigamox and one drop of Acular was placed
upon this right eye. We removed the eyelid speculum as well as the
draping. There was no leaking through the wound and this eye.

I placed an eye shield to protect the eye. The patient tolerated the
surgery well and then entered the recovery room in satisfactory
condition.

ADDENDUM: The patient had limbal relaxing incisions in the right
eye, 40 degrees arc, 1 incision at 79 degrees.