I am having trouble with coding Vitrectomies. I am coming up with different codes and am not sure how to lead to the correct one. For this one i came up with 67113. My doctor told me to code complex anytime the patient has PDR. If someone could please help me i'd really appreciate it. Thanks
PREOPERATIVE DIAGNOSES: 1. Proliferative diabetic retinopathy.
2. Vitreous hemorrhage.
3. Tractional retinal detachment.
Operative site was marked. The patient was brought back to the operating room. Conjunctiva was opened with forceps and Westcott, superonasally, superotemporally, and inferotemporally. Trocars were inserted approximately 3.5 mm posterior to the limbus and the inferotemporal trocar was used for the infusion cannula and was checked for placement in the vitreal cavity, vision was in the vitreous cavity. Core vitrectomy was performed and some peripheral vitrectomy was performed and then attention was turned to the posterior fold. Using a mixture of ILM forceps for peeling and using the cutter, membranes were carefully peeled off the optic nerve, the superior and inferior releasing the traction and retinal detachment. ICG was used to stain the epiretinal membrane and the ILM membrane and a 23-gauge ILM forceps were used to remove the ERM and ILM. Air-fluid exchange was performed and then 23% SF6 air exchange was performed. Conjunctiva was closed with 6-0 chromic, sclera was closed with 7-0 Vicryl and subconjunctival injections of antibiotic and steroid were given. The patient also received a 0.4 mL Sub-Tenon injection of Kenalog and tolerated the procedure well. Ointment was placed and the patient will be seen at the following day in the Eye Clinic for postop management and a 0.0025 mL of 1.25 mg per mL of Avastin was also injected. The patient tolerated the procedure well and will be seen in the Eye Clinic the following day for postop management.