Chapter 15

CPT: 66982-RT ICD: H26.9

CASE 5 PREOPERATIVE DIAGNOSIS: 1. Cataract, right eye. POSTOPERATIVE DIAGNOSIS: 1. Cataract, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: 1. Complex phacoemulsification with manual stretch of the iris, right eye. 2. Peripheral iridectomy, right eye. ANESTHESIA: Topical.(Topical anesthesia is used.) INDICATIONS: The patient was seen in the Ophthalmology office with a complaint of decreased vision in the right eye and was diagnosed with a cataract in the right eye. The patient was symptomatic and therefore, given the option of cataract surgery for improved vision or observation. The details of the procedure were discussed at length as well as the potential risks, which include, but are not limited to, permanent decrease of vision from infection, inflammation, bleeding, retinal detachment and need for reoperation. The patient understood the above and desired to proceed with cataract surgery. DESCRIPTION OF PROCEDURE: The patient received dilating drops and anesthesia in the preoperative area and was later brought into the operating room. The patient was sedated by the anesthesia staff. The patient was then prepped and draped in the usual sterile manner. The microscope was focused onto the right eye and the speculum was inserted to separate the eyelids.(The procedure begins in the right eye.) The tip of the 2.8 mm keratome blade was used at the 6:00 o'clock position to create the paracentesis that after which Amvisc plus was injected into the anterior chamber to create a deep anterior chamber. The same blade was used at 1:00 o'clock to create the main clear corneal wound into the anterior chamber.(This describes the approach.) A two hand technique using iris expansion devices was used to expand the size of the pupil.(Manual iris expansion.) The instruments were used at the sites directly opposite of one another to stretch the iris. They were then rotated 180 degrees to stretch the iris in that new meridian. The cystotome needle on the balanced salt solution syringe was used to initially create the capsulorrhexis flap and the capsulorrhexis forceps were used to create the continuous capsulorrhexis tear.(A capsulorrhexis tear is created.) A flat tip hydrodissection cannula on the balanced salt solution syringe was used to hydrodissect and hydrodelineate the lens. The phacoemulsification unit was used to remove the nucleus and irrigation and aspiration was used to remove the residual cortex.(Phacoemulsification is used to break up the lens so it can be removed.) The bag was inflated with Amvisc plus and a lens of 27.5 diopter model SI40MB was injected into the bag(An intraocular lens is inserted.) and then dialed into place. The Amvisc plus was removed with irrigation and aspiration mode. The anterior chamber was then inflated to the appropriate firmness using balanced salt solution. After the globe was inflated to the appropriate firmness, 0.1 cc of Vancomycin was injected into the anterior chamber. The wounds were checked for leakage and none was found. The globe was checked for appropriate firmness and found to be desirable. The speculum was disinserted and the patient was brought into the postoperative area where postoperative instructions for surgical eye care were given, including the use of topical eye drops and the need for subsequent follow-up. What are the CPT® and ICD-10-CM codes reported?

69631-LT

A 26 year-old female with a one-year history of a left tympanic membrane perforation. She has extensive tympanosclerosis with a nonhealing perforation. Her options, including observation with water precautions or surgery, were discussed. The patient wished to proceed with surgery. With use of the operating microscope, the surgeon performs a left lateral graft tympanoplasty. What CPT® code is reported?

65780

A 53 year-old woman with scarring of the right cornea has significant corneal thinning with a high risk of perforation and underwent reconstruction of the ocular surface. The eye is incised and an operating microscope is used with sponges and forceps to debride necrotic corneal epithelium. Preserved human amniotic membrane is first removed from the storage medium and transplanted by trimming the membrane to fit the thinning area of the cornea then sutured. This process was repeated three times until the area of thinning is flush with surrounding normal thickness cornea. All of the knots are buried and a bandage contact lens is placed with topical antibiotic steroid ointment. What CPT® code is reported?

69300-50

A 6 year-old female with prominent ears undergoes a bilateral otoplasty. Surgeon makes an incision just behind the ear in the natural fold where the ear is joined to the head exposing the cartilage. Cartilage is trimmed and shaped and the incision is closed. Temporary sutures are placed to secure the ear until healing is accomplished. The procedure is repeated on the other ear. What CPT® code is reported?

65855

A 60 year-old female with uncontrolled intraocular pressure and early cataracts is seen for a laser trabeculoplasty. This is her first treatment application. She will be examined over the next three months to ensure the normal inflammations subside. What CPT® code is reported?

67904-E1

A 70 year-old female has a drooping left eyelid obstructing her vision and has consented to having the blepharoptosis repaired. A skin marking pencil was used to outline the external proposed skin incision on the left upper eyelid. The lower edge of the incision was placed in the prominent eyelid crease. The skin was excised to the levator aponeurosis. An attenuated area of levator aponeurosis was dehisced from the lower strip. Three 6-0 silk sutures were then placed in mattress fashion, attaching this attenuated tissue superiorly to the intact tissue inferiorly. This provided moderate elevation of the eyelid. What CPT® code is reported?

67311, 67332

A patient had another recession strabismus procedure of the lateral rectus muscle. This muscle had previously been recessed during an operative session six months ago which resulted in scarring of the extraocular muscle. What CPT® code(s) is/are reported?

68520 RATIONALE: In the CPT® Index, look for Dacryocystectomy referring you to 68520. The stone was embedded in the sac, which was removed. Only one code is used for removal of the stone and removal of the sac. The lacrimal gland is located near the eyebrow; the lacrimal sac is the upper dilated end of the lacrimal duct, aligned with the nostril.

A patient has an oversized and embedded dacryolith in the lacrimal sac, and a dacryocystoectomy is performed. What CPT® code(s) is/are reported for this procedure?

66984-RT Rationale: In the CPT® Index look for Phacoemulsification/Removal/Extracapsular Cataract and you are directed to 66982 and 66984. Verify these codes in the numeric section. Code 66982 is for a complex procedure. There is nothing in the note indicating this is a complex procedure. The correct code is 66984 which includes the insertion of the intraocular lens. Modifier RT is used to indicate it is performed on the right eye.

A patient is diagnosed with nuclear sclerotic cataract, right eye. She is taken to the operating room and a phacoemulsification with intraocular lens, right eye is performed. What code(s) is/are reported?

65103-LT, S05.22XA, V49.59XA, Y92.411

A patient presents to the emergency room with a severely damaged eye. The injury was sustained when the patient was a passenger in a multi-car accident on the public highway. The patient sustained a large open lacerated wound to the left eye. The posterior chamber was ruptured and significant vitreous and some intraocular tissue was lost. The eyeball was not repairable and was removed, en masse. A permanent implant was inserted but not attached to the extraocular muscles. The patient was released with an occlusive eye patch. What CPT® and ICD-10-CM codes are reported?

64612-RT, G24.5

A patient receives chemodenervation with Botulinum toxin injections to stop blepharospasms of the right eye. What are the procedure and diagnosis codes?

69637 RATIONALE: In the CPT® Index, look for Mastoidotomy. Code 69637 represents a mastoidotomy (including atticotomy and tympanic membrane repair) with ossicular chain reconstruction and partial ossicular replacement prosthesis.

A patient underwent mastoidotomy for ossicular chain reconstruction with tympanic membrane repair, atticotomy, and partial ossicular replacement prosthesis. What CPT® code is reported for this procedure?

69300-50, Q17.5

A patient with right and left prominent ears presents for an otoplasty. What CPT® and ICD-10-CM codes are reported?

69799 RATIONALE: In the CPT® Index, look for Ear/Unlisted Services and Procedures. The correct answer is A, for an unlisted procedure. Round window implants are a new technology not yet assigned CPT® a code. The word transducer should alert you to the hearing aid component of this procedure. There isn't a new technology Category III code for this type of procedure so an unlisted code is the best choice. The round window is the barrier between the middle and inner ear, but it is still considered middle ear.

A patient with severe mixed hearing loss from chronic otitis media undergoes a round window implant with floating mass transducer. What CPT® code is reported for this procedure?

H26.9 Rationale: In the ICD-10-CM Alphabetical Index look for Opacity, opacities/lens which states see Cataract. Look in the Alphabetic Index for Cataract and you are directed to the default code H26.9. Confirmation in the Tabular List confirms code selection.

An 89 year-old patient who has significant partial opacities in the lens of the left eye presents for phacoemulsification and lens implantation. What ICD-10-CM code is reported?

92012 RATIONALE: In the CPT® Index, look for Ophthalmology, Diagnostic/Eye Exam/Established Patient referring you to 92012-92014. A comprehensive exam includes a biomicroscopy and tonometery. Code 92002 is reported for a new patient and 92012 for an existing patient. This service is for an existing patient, making 92012 the correct code.

The ophthalmologist performs a review of history, external ocular and adnexal exam, ophthalmoscopy, biomicroscopy and tonometry on an established patient with a new cataract. What CPT® code is reported for this procedure?

CPT: 67107-RT ICD: H33.021

CASE 1 ANESTHESIA: Laryngeal mask anesthesia. PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye. POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right eye. PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye. A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors. Each of the intramuscular quadrants was dissected using Aebli scissors. The muscles were isolated using a Gass muscle hook with an 0 silk suture attached to it. The patient had an inspection of the intramuscular quadrants and there was no evidence of any anomalous vortex veins or thin sclera. The patient had an examination of the retina using an indirect ophthalmoscope and he was noted to have 3 tears in the temporal and inferotemporal quadrant and 2 tears in the superior temporal quadrant. (Exam reveals the location of the tears.) These were treated with cryoretinopexy.(Cryoretinopexy is the use of intense cold to close the tear in the retina.) Most posterior edge of each of the tears was marked with a scleral marker followed by a surgical marking pen. The patient had 5-0 nylon sutures placed in each of the 4 intramuscular quadrants. The 2 temporal sutures were placed with the anterior bite at about the muscle insertion, the posterior bite 9 mm posterior to this. In the nasal quadrants, the anterior bite was 3 mm posterior to the muscle insertion and the posterior bite was 3 mm posterior to this. A 240 band was placed 360 degrees around the eye and a 277 element from approximately the 5-1 o'clock position. The patient had another examination of the retina and was noted to have a moderate amount of subretinal fluid, so a drainage sclerotomy site was created at approximately the 9:30 o'clock position incising the sclera until the choroid was visible.(A sclerotomy is performed to drain subretinal fluid.) The choroid was then punctured with a #30-gauge needle. A moderate amount of subretinal fluid was drained from the subretinal space. The eye became relatively soft and 0.35 ml of C3FS gas was injected into the vitreous cavity 3.5 mm posterior to the limbus. The superior temporal and inferior temporal and superior nasal sutures were tied down over the scleral buckle. The 240 band was tightened up and excessive scleral buckling material was removed from the eye.(Sclera buckling is performed.) The inferior nasal suture was tied down over the scleral buckle and all knots were rotated posteriorly. The eye was reexamined. The optic nerve was noted to be nicely perfused. The tears were supported on the scleral buckle. There was a small amount of residual subretinal fluid. The patient received posterior sub-Tenon Marcaine for postoperative pain control. The 0 silk sutures were removed from the eye. The conjunctiva was closed with #6-0 plain gut suture. The patient received subconjunctival Ancef and dexamethasone. The patient was patched with atropine and Maxitrol ointment. The patient tolerated the procedure well and returned to the postoperative recovery room. What are the CPT® and ICD-10-CM codes reported?

CPT: 15260-E2, 67966-51-LT, 67971-51-LT, 67875-51 ICD: C44.1192

CASE 10 Preoperative Diagnosis: Left lower eyelid basal cell carcinoma Postoperative Diagnosis: Left lower eyelid basal cell carcinoma Operation: Excision of left lower eyelid basal cell carcinoma with flaps and full thickness skin graft and tarsorrhaphy. Indication for surgery: The patient is a very pleasant female who complains of a one-year history of a left lower eyelid lesion. This was recently biopsied and found to be basal cell carcinoma. She was advised that she would benefit from a complete excision of the left lower eyelid lesion. She is aware of the risks of residual tumor, infection, bleeding, scarring and possible need for further surgery. All questions have been answered prior to the day of surgery. She consents to the surgery. Operative Procedure: The patient was placed supine on the operating table and an intravenous line was established by hospital staff prior to sedation and analgesia. Throughout the entire case, the patient received monitored anesthesia care. The patient's entire face was prepped and draped in the usual sterile fashion with a Betadine solution and topical tetracaine and corneal protective shields were placed over both corneas. A surgical marking pen was used to mark the tumor. Markings that were 3 mm were obtained around the tumor. The tumor was noted to encompass approximately 1/3 of the left lower eyelid. A wedge resection was performed and this was marked and 2% Xylocaine with 1:100,000 epinephrine, 0.5% Marcaine with 1:100,000 epinephrine was infiltrated around the lesion. This was excised with a #15 blade. This was sent for intraoperative fresh frozen sections. Intraoperative fresh frozen sections revealed persistent basal cell carcinoma at the medial margin. Another 2mm of margin was discarded and a revised left lower eyelid medial margin was sent for permanent sections. The area could not be closed primarily, thus a tarsoconjunctival advancement flap was advanced from the left upper eyelid to fill the defect. This was sutured in place with multiple 5-0 Vicryl sutures. The anterior lamella defect of skin was closed by harvesting a full-thickness skin graft from the left upper eyelid and placing it in the left lower eyelid defect. This was sutured in place with multiple interrupted 5-0 chromic gut sutures. The eyelids were sutured shut both on the medial aspect of the Hughes flap as well as the lateral aspect of the Hughes flap with a 4-0 silk suture. A pressure dressing and TobraDex ointment were applied. The patient tolerated the procedure well and was transported back to the recovery area in excellent condition. What are the CPT® and ICD-10-CM codes reported?

CPT: 68811-50 ICD: H04.553

CASE 2 PREOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes. POSTOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes. PROCEDURE PERFORMED: Nasolacrimal duct probing, both eyes. ANESTHESIA: General. CONDITION: To recovery, satisfactory. COUNTS: Needle count correct. ESTIMATED BLOOD LOSS: Less than 1 ml. INFORMED CONSENT: The procedure, risks, benefits, and alternatives were thoroughly explained to the patient's parent who understands and wants the procedure done. PROCEDURE: The patient was prepped and draped in the usual sterile manner under general anesthesia.(General anesthesia is used for this procedure.) Starting on the right eye (This indicates the procedure is performed on the right eye.) the upper punctum was dilated with double-ended punctal dilator, and starting with a 4-0 probe, increasing up to a 2-0 probe, the nasolacrimal duct was dilated until probed patent.(This indicates the nasolacrimal duct is probed.) Then, using a curved 23-gauge punctal irrigator, 0.125 ml of sterile fluorescein stained saline was easily irrigated down the nasolacrimal duct into the nostril where it was carefully collected with a clear #8 catheter. The instruments were removed and an identical procedure was done on the opposite eye nasolacrimal duct.(The same procedure is performed on the left eye.) TobraDex eye drops were placed in each lower cul-de-sac. The eyelids were closed. The patient left the operating room for recovery in satisfactory condition, accompanied by myself and Dr. Smith. What are the CPT® and ICD-10-CM codes reported?

CPT: 69300-50 ICD: Q17.5

CASE 3 PREOPERATIVE DIAGNOSIS: Bilateral protruding ears. POSTOPERATIVE DIAGNOSIS: Bilateral protruding ears. PROCEDURE: Bilateral otoplasty. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. COMPLICATIONS: None. PROCEDURE IS AS FOLLOWS: The patient was placed supine then prepped and draped in the usual sterile fashion. Measurements were taken from the helix to the mastoid at the superior, mid, and inferior portions and they were within 1 to 2 mm of the same bilaterally and were approximately 17 mm superior, 24 mm middle, and 25 mm inferior. The right ear was begun first.(Procedure is performed on the right ear.) A curved incision was made just anterior to the sulcus (An incision is made.) of the posterior ear. This was done with a 15-blade scalpel. Electrocautery was used for hemostasis and further dissection. An iris scissors was used to dissect the soft tissues off of the mastoid region and the posterior ear. The concha was shut back and sutured in place with clear 4-0 nylon suture and in a horizontal mattress pattern.(The concha, which is the external part of the ear, is sutured in place.) Three tacking sutures were used. This brought the ear back approximately 2 to 3 mm. However, greater correction was needed and Mustarde' sutures were placed. (This is a suturing technique used to perform otoplasty.) The mid and superior portions of the antihelical fold were placed.(There are a total of three portions of the external ear that are repaired during this otoplasty.) These were spaced widely on either side of the helical fold. They were then sutured in place, tacking the fold more acutely to a point that was deemed acceptable and held in that position. Next, a margin of skin was excised along the posterior ear and closure of the wound was performed with 5-0 chromic suture. Prior to closure, full hemostasis had been obtained with electrocautery. Both ears were done in the exact same fashion; therefore only one is dictated in detail. (This indicates that a bilateral procedure is performed.) The patient was then checked very carefully for symmetry. Postoperative measurements were approximately 14 mm superior, 15 mm mid, and 16 mm lower. What are the CPT ® and ICD-10-CM codes reported?

CPT: 69205-RT ICD: T16.1XXA

CASE 4 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Foreign body, right external ear canal. ANESTHETIC: General. Time began: 10:15 a.m. Time ended: 10:35 a.m. POSTOPERATIVE DIAGNOSIS: Foreign body, right external ear canal.(The postoperative diagnosis is used for coding.) PATHOLOGY SPECIMEN: None. OPERATION: Removal of foreign body using the microscope. DATE OF PROCEDURE: 05/12/XX Time began: 10:21 a.m. Time ended: 10:22 a.m. DESCRIPTION OF OPERATION: Under general anesthesia(General anesthesia is used.) with the microscope in place, a pearly white plastic ball was seen virtually obstructing the entire ear canal. Gently with a curette, this was teased out of the ear canal atraumatically.(The foreign body is removed.) The ear canal and eardrum were perfectly intact. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition What are the CPT® and ICD-10-CM codes reported?

CPT: 66984-LT ICD: H26.9

CASE 6 IV SEDATION AND LOCAL PREOPERATIVE DIAGNOSIS: Cataract of the left eye POSTOPERATIVE DIAGNOSIS: Cataract of the left eye Cataract extraction, foldable posterior chamber intraocular lens of the left eye PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. An intravenous line was started in the patient's left arm. After appropriate sedation, a left O'Brien and left retrobulbar block were administered, which consisted of a 50/60 mixture of 0.75% Bupivacaine and 2% lidocaine. The Honan balloon was then placed over the operative eye. While the surgeon scrubbed for 5 minutes the patient was prepped and draped in the usual sterile fashion including instillation of 5% Betadine solution to the left cornea and cul-de-sac, which was irrigated with balanced salt solution and the use an eyelid drape. A limbal incision was performed with the super sharp blade. Provisc was injected into the anterior chamber. A capsulotomy was performed with a cystitome and Utrata forceps such that it was 6 mm and oval in shape. Hydrodissection was performed with balanced salt solution. The nucleus was removed using the phacoemulsification mode of the Alcon 20,000 Legacy Series System by divide and conquer technique under Viscoat control. The cortex was removed using the irrigation aspiration mode. The anterior chamber was then filled with Proviso and the AcrySof foldable posterior chamber intraocular lens was then inserted into the capsular bag and rotated into position such that the optic was well centered. The Proviso was removed using the irrigation and aspiration mode. Miochol was injected to constrict the pupil. The wound was checked and deemed to be watertight. A collagen shield soaked in Ciloxan and Pred Forte was applied. The standard postoperative patch and shield were placed and the patient was transferred to the Recovery Room in stable condition. What are the CPT® and ICD-10-CM codes reported?

CPT: 69620-RT ICD: H72.01, H90.11, H74.01

CASE 7 PREOPERATIVE DIAGNOSIS: Tympanic membrane perforation, conductive hearing loss in the right ear. POSTOPERATIVE DIAGNOSIS: Tympanic membrane perforation, conductive hearing loss in the right ear. NAME OF PROCEDURE: Right tympanoplasty via the postauricular approach. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Less than 20 ml. COMPLICATIONS: None. SPECIMENS: None. INDICATIONS: This is a 9 year-old white female with the above diagnoses and now presents for surgical intervention. INTRAOPERATIVE FINDINGS: Intraoperative findings revealed tympanosclerosis posteriorly with a central eardrum perforation of approximately 30% of the surface of the eardrum. There was no cholesteatoma. The ossicular chain is intact. DESCRIPTION OF OPERATTVE PROCEDURE: Under satisfactory general anesthesia the patient was given preoperative intravenous antibiotic. The right ear was prepared and draped in the usual sterile fashion. A postauricular incision was made and the temporalis fascia graft was harvested. The posterior ear canal skin was elevated and tympanomeatal flap was developed. The Rosen needle was used to freshen the edge of the perforation. Gelfoam was placed in the middle ear space. The graft was cut into the appropriate size and laid medial to the remnant of the tympanic membrane anteriorly, posteriorly, inferiorly and superiorly. Antibiotic ointment and Gelfoam were placed in the ear canal. Closure of the wound was done in layers with 4-0 Vicryl for the subcutaneous tissue and 4-0 Prolene for skin. Pressure dressing was placed around the right ear. The patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported?

CPT: 69660-RT, 21235-51-RT ICD: H80.81

CASE 8 PREOPERATIVE DIAGNOSIS: Right otosclerosis. POSTOPERATIVE DIAGNOSIS: Right otosclerosis. TYPE OF PROCEDURE: Right stapedectomy. ANESTHESIA: General endotracheal. FINDINGS: There was otosclerosis on the anterior footplate of the stapes with preoperative conductive hearing loss in the right ear. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. Following induction of general endotracheal anesthesia, the head was turned to the left and the right ear was prepped and draped in the usual fashion. Then 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the skin along the posterior ear canal wall and the skin over the tragus. After a short waiting time, an incision was made over the tragus and a piece of posterior tragal perichondrium was harvested for a graft and set aside to dry. A speculum was then placed in the canal. The canal was quite large. An incision was made along the posterior canal wall, and a tympanomeatal flap was elevated and laid forward to include the fibrous annulus without perforation. The middle ear was inspected. The ossicular chain was palpated and otosclerosis appeared to be fixing the stapes. The chorda tympani nerve was very carefully preserved and not manipulated and was kept moist throughout the procedure. No curetting of bone was necessary in order to access the footplate. A control hole was made in the footplate with a straight pick. The incudostapedial joint was separated with an IS joint knife. The stapedius tendon was severed, and the superstructure of the stapes was fractured over the promontory and removed. The footplate was then picked out with a 45-degree pick, completely removing all fragments. Great care was taken not to suction in the vestibule. The distance between the incus and the oval window was then measured. The tragal perichondrial graft was then taken and laid over the oval window with complete coverage. A 3.75 Shea platinum Teflon cup piston was then chosen. The platinum wires were opened and the shaft was placed down against the graft and into the oval window niche. The cup was placed under the long process of the incus by gently lifting the incus, and the platinum wires were snugly crimped around the long process of the incus. An excellent round window reflex was achieved upon palpation of the ossicular chain at this point. Small, dry, pressed Gelfoam pledgets were then placed around the shaft of the prosthesis and over the graft. The tympanomeatal flap was replaced. The lateral surface of the drum was covered with Gelfoam, and the canal was filled with antibiotic ointment. The incision over the tragus was closed with running, interlocking 5-0 plain, fast-absorbing gut. A cotton ball was placed in the canal, and the patient was awakened, extubated, and returned to recovery in satisfactory condition. He will be discharged when fully awake and will return to my office in two weeks. He will avoid strenuous activity, keep the ear dry, keep a clean cotton ball in the ear, apply antibiotic ointment to the tragal incision, avoid driving while dizzy, and he was given prescriptions for Lorcet Plus, Keflex, and Xanax. What are the CPT® and ICD-10-CM codes reported?

CPT: 42830, 69436-51-50 ICD: J35.2, H65.93

CASE 9 PREOPERATIVE DIAGNOSIS: Adenoidal hypertrophy and serous otitis media with effusion. POSTOPERATIVE DIAGNOSIS: Adenoidal hypertrophy and serous otitis media with effusion. NAME OF PROCEDURE; Bilateral ventilation tube placement, Donaldson-Activent type, Adenoidectomy. ANESTHESIA: General ESTIMATED BLOOD LOSS: Less than 5 ml. FINDINGS: The patient is an 18 month old white male with a history of the above noted diagnosis. Operative findings included bilateral thickened drums. He had a right and left serous effusion. The left was aerated for the most part. He had an intact palate and a 3-4 + adenoid pad. TECHNIQUE: Patient was brought into the operative suite and comfortably positioned on the table. General mask anesthesia was induced. Appropriate drapes were placed. Attention was turned to the right ear. The external canal was cleaned of cerumen and irrigated with alcohol. A radial incision was made in the right tympanic membrane. Middle ear was evacuated of effusion and Donaldson-Activent tube was followed by Ciprodex otic drops. The same procedure was performed on the contralateral side. The bed was turned 30° m clockwise fashion. The Crowe-Davis mouth gag was inserted and suspended. The palate was palpated and felt to be intact. The soft palate was elevated and under direct nasopharyngoscopy. The adenoid was removed with powered adenoidectomy blade taking care to avoid injury to the Eustachian tube orifice. The base was cauterized with Bovie suction cautery and a pack was placed. After several minutes, the packs were removed. The nasopharynx and oral cavity was irrigated and suctioned free of debris. The stomach was evacuated with orogastric tube. Re-evaluation showed no further active bleeding. Further drapes and instruments were removed. The patient was returned to the care of Anesthesia, allowed to awaken, extubated and transported in stable condition to the recovery room having tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported?

Air conduction RATIONALE: The hearing of a patient is interrupted by impacted earwax, called cerumen. The wax interrupts air conduction of sound as it travels through the ear canal across the tympanic membrane to the middle and inner ear. Bone conduction is not affected by earwax buildup.

Code 69210 in the CPT® book describes removal of impacted earwax from the external auditory canal. What type of conduction is interrupted by impacted earwax?

H91.90 RATIONALE: Without more specific information for the type of hearing loss, a nonspecific diagnosis is reported. In the ICD-10-CM Alphabetic Index, look for Loss/hearing (see also Deafness). Look for Deafness directing you to H91.9-. In the Tabular List, select code H91.90 Unspecified hearing loss, unspecified ear. No scientific study of the hearing loss was made, making R94.120 incorrect.

Mable reports her hearing is not what it used to be. Indeed, everything that was discussed today during her visit has been repeated loudly, and within very close range. The physician scheduled a hearing testing with Acme Audiology. What is the diagnosis code?

67010 Rationale: In the CPT® Index look for Vitrectomy/Anterior Approach/Subtotal. This was a subtotal removal using a mechanical tool to sweep the vitreous away. Subtotal using a mechanical tool is reported with 67010.

Operative Report PREOPERATIVE DIAGNOSIS: Prolapsed vitreous in anterior chamber with corneal edema POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Anterior vitrectomy The patient is a 72 year-old woman who approximately 10 months ago underwent cataract surgery with a YAG laser capsulotomy, developed corneal edema and required a corneal transplant. The patient has done well. Over the last few weeks, she developed posterior vitreous detachment with vitreous prolapse to the opening in the posterior capsule with vitreous into the anterior chamber with corneal touch and adhesion to the graft host junction and early corneal edema. The patient is admitted for anterior vitrectomy. PROCEDURE: The patient was prepped, and draped in the usual manner after first undergoing retrobulbar anesthetic. A lid speculum was inserted. An incision was made at approximately the 10 o'clock meridian 3 mm in length, 2 mm posterior to the limbus, and grooved forward into clear cornea with a 3.2 mm anterior chamber. An anterior vitrectomy was carried out, placing a visco-elastic substance in the anterior chamber to maintain it. A Sinskey hook was used to sweep vitreous away from the corneal wound and this was removed with the disposable vitrectomy instrument. The patient's pupil is noted to be round. There was no vitreous to the wound. The wound self-sealed without aqueous leak. Cautery was used to close the conjunctiva. Subconjunctival Decadron and Gentamicin was given. The patient tolerated the procedure well and was discharged to the recovery room in good condition. What CPT® code(s) is/are reported?

69436-RT, H65.21

Parents of a 3 year-old male who has chronic serous otitis media in the right ear have consented to surgery. Patient is placed under general anesthesia and the provider makes an incision in the tympanic membrane. Fluid is suctioned out from the middle ear and a ventilating tube is placed in the ear to provide a drainage route to help reduce middle ear infections. What CPT® and ICD-10-CM codes are reported?

67113, H33.031, W21.03XA Rationale: In the CPT® Index look for Retina/Repair/Detachment/with Vitrectomy referring you to 67108, 67113. Code 67113 is used for the repair of a giant tear of the retina, with vitrectomy, and endolaser photocoagulation. In the ICD-10-CM Alphabetical Index look for Detachment/retina/with retinal/break/giant referring you to H33.03-. In the Tabular List a 6th character 1 is reported for the right eye. In the ICD-10-CM External Cause of Injuries Index look for Struck (accidentally) by/ball (hit) (thrown)/baseball referring you to W21.03-. In the Tabular List seven characters are reported to complete the code. The 6th character is a placeholder X and the 7th character A is used to identify the initial encounter. Surgical management represents an initial encounter.

Repair of right eye retinal detachment with a giant tear is performed for an accidental injury sustained from a baseball to the eye at fastball practice. Vitrectomy, drainage of subretinal fluid, silicone oil tamponade, and endolaser photocoagulation are performed to correct the tear. What are the procedure and diagnosis codes for this service?

69105 RATIONALE: Although the area biopsied is skin, a code from the Auditory System chapter of CPT® is appropriate for this biopsy. CPT® tells us to report code 69100 for a biopsy of the external ear, and 69105 for a biopsy of the external auditory canal. In the CPT® Index, see Biopsy/Auditory Canal, External 69105. The tragus is the protective cartilage knob anterior to the ear canal. Code 69105 is the correct code for a biopsy, by any method of the external auditory canal.

The 55 year-old patient presents with 1 cm lesion in his right ear canal posterior to the tragus. The lesion is red and raised, typical of basal cell carcinoma. After administration of lidocaine, I performed a shave biopsy. Electrocautery was required to control bleeding. The tissue sample was sent to pathology. What CPT® code is reported for this procedure?

The middle ear RATIONALE: The three ossicles (malleus, incus, and stapes) are found in the middle ear. When sound travels by air into the external auditory canal, it causes the tympanic membrane to vibrate. The sound is then transferred from the membrane to the tiny ossicles. From the stapes, the vibration is transferred to the oval window, which causes the round window to move and vibrate the endolymph of the cochlear duct. This causes the fine hairs in the organ of Corti to transmit impulses through the cochlear nerve to the brain.

The incus bone is between the malleus and the stapes. In which part of the ear is the incus located?

C72.40 RATIONALE: In the ICD-10-CM Alphabetic Index look for Neuroma/acoustic (nerve) D33.3. Although an acoustic neuroma is indexed to D33.3, the question indicates malignant which changes the way the diagnosis is reported. A note at the beginning of the Table of Neoplasms discusses classifications in the columns of the table, and advises, "the guidance in the index can be overridden if one of the descriptors is present." Because the pathologist stated this particular acoustic neuroma is malignant, the word malignant overrides the index entry. Look in the Table of Neoplasms for Neoplasm, neoplastic/acoustic nerve/Malignant Primary which directs you to C72.4-. Verify in the Tabular List and code C72.40 is reported because the laterality is not addressed. It's very important to study and understand the information provided in the guidelines and notes within the codebook. Be willing to look beyond the codes for the answers because the answers may be in the instructional notes and guidelines.

The pathology report comes back and the tumor is a malignant acoustic schwannoma. What is the correct diagnosis code?

H40.9 RATIONALE: There is not a lot of information to work with and H40.9 Unspecified glaucoma is the appropriate choice. In the ICD-10-CM Alphabetic Index, look for Glaucoma and the default code is H40.9. In a medical office, you would have access to the entire patient record and to the physician to find out more about the type of glaucoma. The important thing to remember is the patient still has glaucoma, despite the normal (WNL is within normal limits) IOP (intraocular pressure). Code Z86.69 is inappropriate because it reports a history of a resolved condition.

The patient has been compliant with his Xalatan eye drops and his intraocular pressure (IOP) is now within normal limits at 20 mm Hg. The glaucoma seems to be in good control. He will continue the current regime and return for a follow-up exam in six months. What diagnosis code is reported?

67318, 67331, 67335 RATIONALE: In the CPT® Index, look for Strabismus/Repair/Superior Oblique Muscle 67318. Code 67318 is the only code listed describing a procedure on the superior oblique muscle. In addition to 67318, report add-on codes for adjustable sutures. In the index, see Strabismus/Repair/Adjustable Sutures 67335. This patient has a history of ophthalmic surgery . The medical history of ocular surgery makes the procedure riskier and more difficult. Look in the index for Strabismus/Repair/Previous Surgery, Not Involving Extraocular Muscles 673331. Modifier 51 never is applied to add-on codes.

The patient has hypertropia in her right eye with prior eye operations in this eye and today we are performing a recession of the superior oblique muscle to balance this muscle and eliminate strabismus. Adjustable sutures are applied. She is pseudophakic. What CPT® codes are reported for this procedure?

E10.3292 RATIONALE: In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic/type 1/with/retinopathy/non-proliferative/mild and directs you to E10.329. In the Tabular List, 7th character 2 is reported to indicate the left eye. This is a combination code that includes the diabetes and the complication of retinopathy. A separate code for retinopathy is not reported. Because macular edema is not indicated in the scenario, the default is without macular edema.

The patient is a 40-year-old male with type I diabetes in good control. He is seen today for a follow up of his mild nonproliferative diabetic retinopathy in the left eye. Select the correct diagnosis code(s).

S09.21XA, W60.XXXA, Y92.017, Y93.H2 RATIONALE: This is an acute injury and in ICD-10-CM injuries have different categories for open wounds, lacerations, bites, and are specific to with or without a foreign body. In the ICD-10-CM Alphabetic Index, look for Wound/puncture wound - see Puncture. Look for Puncture/ear/drum directing you to S09.2-. In the Tabular List subcategory S09.2- requires a 5th digit for laterality and a 7th character for the type of encounter. Because S90.21 is a five-character code, the place holder X is needed to maintain the 7th character position. The complete code is S09.21XA. Codes in the H72.0- subcategory are for perforations persisting after an illness or injury is resolved. Code S00.401- is for a superficial injury, but this isn't superficial because it is in the middle ear. Do not confuse simple with superficial. External cause codes describe the circumstance of the injury. These codes are found in External Cause Of Injuries Index. Look for Contact/with/plant thorns, spines, sharp leaves or other mechanisms W60.Category W60 requires a 7th character for type of encounter. Because this is a three-character code, the placeholder X is needed to maintain the 7th character position. The complete code is W60.XXXA.. Next, in the External Cause Of Injuries Index for look for Place of occurrence/yard, private/single family house Y92.017. In the same index look for Activity/gardening Y93.H2. Verify these codes in the Tabular List. These External cause codes help establish the cause of the injury for the payer.

The patient reports she turned her head quickly while pruning a dogwood tree in her yard and a branch entered her right ear. She states that when she performs a Valsalva maneuver (exhaling with the mouth and nose firmly closed), she can hear air course through her ear. On examination, there is no foreign body present. A small perforation of the right eardrum is noted, which should heal independent of treatment. Her ear will be re-evaluated in two weeks. Select the correct diagnosis codes.

69310 RATIONALE: In the CPT® Index, see Meatoplasty/External Auditory Canal 69310. The external opening of the ear is referred to as the meatus. A meatoplasty enlarges the opening. Another index option is to look for Auditory Canal/External/Reconstruction/for Stenosis 69310.

The patient underwent a plastic repair of the external auditory canal for stenosis, a late effect of a burn. After excising the subepithelial stenotic tissue and a wedge of skin from the floor of the external auditory canal, a rubber tube was placed inside the external canal. The patient will return in two weeks to monitor his progress. What CPT® code is reported for this procedure?

T85.79XA, H05.011, Z85.840 RATIONALE: In the ICD-10-CM Alphabetic Index, look for Complication/eye/implant (prosthetic)/infection and inflammation directing you to T85.79-. In the Tabular List, code T85.79- requires a 7th character. Based on active treatment for the condition this would support A, initial encounter. Because T85.79 is a five character code the place holder X is needed to maintain the 7th character position. Subcategory code T85.7 states to "Use additional code to identify specified infections". There is no documentation of the infective agent. Orbital cellulitis is indexed under Cellulitis/orbit, orbital H05.01-. In the Tabular List, the 6th character 1 is for the right side. The implant is the result of the patient's previous cancer indicated with Z85.840. This is found under History/personal (of)/malignant neoplasm (of)/eye Z85.840. This is not a family history of cancer of the eye, Z80.8.

The patient underwent an enucleation for retinal cancer and is here today with right orbital cellulitis, a foreign body response to the temporary implant placed following the surgery. The implant was removed, and the patient was admitted for observation and IV antibiotics. Select the correct diagnosis codes.

69420, H68.012

The provider makes an incision in the patient's left tympanic membrane in order to inflate eustachian tubes and aspirate fluid in a patient with acute eustachian salpingitis. The procedure is completed without anesthesia. What CPT® and ICD-10-CM codes are reported?

65420-50 RATIONALE: In the CPT® Index, see Pterygium/Excision 65420. A pterygium is an overgrowth of conjunctiva forming in the nasal aspect of the eye and growing outward toward the cornea. Excision of a pterygium is reported separately from other conjunctival disorders, with codes 65420 and 65426. Because this was a simple repair without a graft, 65420 is the correct code. Modifier 50 indicates a bilateral procedure was performed.

Today we excised bilateral recurrent pterygiums under topical anesthetic. The conjunctival incisions were repaired simply. What CPT® code is reported for this procedure?

H10.023 RATIONALE: Pink eye is a highly infectious form of mucopurulent conjunctivitis. This infection typically is accompanied by very bloodshot eyes and a heavy discharge. In the ICD-10-CM Alphabetic Index, look for Pink/eye - see Conjunctivitis, acute, mucopurulent. Look for Conjunctivitis/acute/mucopurulent H10.02-. In the Tabular List, the codes contain laterality and documentation indicates both eyes (bilateral) are affected.

Topical antibiotics were prescribed today for Jack Jones, who presented with pink eye in both eyes. His four children are all being treated for the same condition by their pediatrician. What is the correct diagnosis code?

69636-RT Rationale: In the CPT® Index look for Tympanoplasty/with Antrotomy or Mastoidotomy/with Ossicular Chain Reconstruction and you are directed to 69636. Append modifier RT to identify the procedure is performed on the right ear.

What CPT® code is reported for a tympanoplasty with mastoidotomy and with ossicular chain reconstruction in the right ear?

69200

What CPT® code is reported for removal of foreign body from the external auditory canal without general anesthesia?

67120 RATIONALE: An aqueous shunt is implanted material in the extraocular posterior segment of the eye. In the CPT® Index, look for Eye/Removal/Implant/Posterior Segment referring you to 67120-67121. It can also be found by looking for Removal/Implant/Eye.

What CPT® code is used to report surgery to remove an aqueous shunt from the patient's extraocular posterior segment of the eye?

Z13.5

What ICD-10-CM code is reported for an encounter for cataract screening?

H65.493

What ICD-10-CM code is reported for bilateral chronic otitis media with effusion?

E11.3219

What ICD-10-CM code is reported for mild nonproliferative diabetic retinopathy with macular edema?

H66.41

What ICD-10-CM code is reported for suppurative otitis media in the right ear?

Intraocular lens

What does IOL stand for?

Laterality (eye affected). Rationale: ICD-10-CM lists many of the codes for eye disorders or injuries based on which eye was affected (laterality - left, right, bilateral or unspecified).

What information does ICD-10-CM add to many of the codes for eye disorders or injuries?

Surgical repair of the eyelid. RATIONALE: Blephar/o is a root word identifying the eyelid, and plasty indicates a surgical repair.

What is a blepharoplasty?

Protrusion of the eyeballs.

What is exophthalmos?

O.U.

What is the abbreviation for EACH EYE?

The tympanic membrane is incised. RATIONALE: Myring/a is a root word identifying the tympanic membrane and -otomy is a suffix indicating an incision.

What occurs in myringotomy?

Iris RATIONALE: The iris is the colorful muscle contracting and expanding in a measured fashion, controlling the amount of light permitted into the posterior segment of the eye. While the iris is involved in rationing light, it does not have any effect on the bending of light. As an opaque body, the iris has no refractive qualities.

Which of the following has NO refractive properties?

S01.312A, Z23 RATIONALE: This is an open wound of the earlobe. In the ICD-10-CM Alphabetic Index look for Laceration/ear (canal) (external), which directs you to S01.31-. In the Tabular List, the code selection indicates a 6th character for laterality and 7th character to indicate the episode of care is required. Complete code S01.312A is for laceration of the left ear, initial encounter. The patient received a vaccination for tetanus, which is reported with Z23. Look in the Alphabetic Index for Vaccination/encounter for directs you to Z23.

While dressing for work, the patient caught her earring in her shirt, and the force of her arm's motion ripped the earring free, tearing her earlobe. She is seen in the emergency department to have the left earlobe repaired and to receive a tetanus shot. What diagnosis codes are assigned?