Chapter 15 Review

Under general anesthesia, a provider excises one chalazion from each upper eyelid. What are the procedure and diagnosis codes for the service?

67808-E1-E3, H00.11, H00.14 Rationale: In the CPT® Index look for Chalazion/Excision/Under Anesthesia directing you to 67808. Code 67808 describes the use of general anesthesia to excise single or multiple chalazion(s). Modifiers E1 and E3 can be reported to indicate which eyelids were operated on. In the ICD-10-CM Alphabetic Index look for Chalazion/right/upper H00.11 and Chalazion/left/upper H00.14. Verify code selection in the Tabular List.

What ICD-10-CM code(s) is/are reported for bilateral cataracts?

H26.9 Rationale: In the ICD-10-CM Alphabetic Index look for Cataract and you are directed to the default code H26.9. Modifiers are not appended to diagnosis codes. There is no documentation to support that the cataracts are congenital. Even though the cataract is in both eyes, it is only necessary to report the ICD-10-CM code once per ICD-10-CM guideline I.B.12.

What does IOL stand for?

Intraocular lens Rationale: IOL stands for intraocular lens.

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

64612-RT, G24.5 Rationale: In the CPT® Index look for Chemodenervation/Facial Muscle 64612, 64615. Code 64612 is used for chemodenervation of muscles that are innervated by the facial nerve for conditions such as blepharospasm. Modifier RT is appended to the CPT® code to indicate the procedure is performed on the right eye. Botulinum toxin is the substance most commonly used for chemodenervation of muscle tissue innervated by the facial nerve. In the ICD-10-CM Alphabetic Index look for Blepharospasm directs you to G24.5. Verification in the Tabular List confirms code selection.

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?

65103-LT, S05.22XA, V49.59XA, Y92.411 Rationale: Enucleation is the removal of the eye. At the time of surgery, an implant was inserted and extraocular muscles were not attached to it. In the CPT® Index look for Enucleation/Eye which gives codes 65101, 65103, 65105. Code 65103 best describes this procedure. The LT modifier is appended to indicate that this was the left eye. In the ICD-10-CM Alphabetical Index look for Laceration/eye (ball)/with prolapse or loss of intraocular tissue directing you to S05.2-. Tabular List indicates that seven characters are reported to complete the code. The 5 th character 2 is reported to indicate left eye. X is used as placeholder for the 6 th character position. The 7 th character is A to report initial encounter for the patient receiving active treatment in the ED. Documentation does not provide sufficient details of the multi-car accident to specify whether the other cars were in motion and if a collision occurred with other objects/persons. Look in the ICD-10-CM External Cause of Injuries Index for Accident/transport/car occupant/passenger/collision (with)/motor vehicle NOS (traffic)/specified type NEC (traffic) V49.59-. The 6 th character X is used as a placeholder and 7 th character A for initial encounter in the ED. Look for Place of occurrence/highway (interstate) directing you to Y92.411.

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?

65855 Rationale: In the CPT® Index look for Trabeculoplasty/by Laser Surgery directing you to 65855. Verify this in the numeric section. Code 65855 is the correct code since trabeculoplasty by laser surgery was performed on the patient.

A 65 year-old male with a history of chronic glaucoma has progressive optic nerve damage and elevated intraocular pressure. A clear corneal incision is made and viscoelastic material is injected into the anterior chamber over the lens to increase and maintain anterior chamber depth. The endoscope is inserted through the temporal incision to view the nasal ciliary processes, which is coagulated with the endpoint of shrinkage and whitening. The endoscope is moved in an arc, allowing treatment of the processes over an arc of 180° and a second corneal incision is made 90° away and 180° of ciliary processes are destroyed with laser therapy. The surgeon has completed coagulation of 270° of angle. The eye is reformed with balanced salt solution. Wounds are checked for leakage and sutures are placed to seal the wound. What CPT® code is reported?

66711 Rationale: In the CPT® Index look for Ciliary Body/Destruction/Cyclophotocoagulation 66710, 66711. Code 66711 is the correct code because using an endoscopic approach, ciliary processes were coagulated and were destroyed by laser therapy.

The provider creates an opening in the opaque posterior lens capsule of the patient's right eye by cutting an inverted U shape in the tissue. The cut is made using a YAG laser. The tissue within the inverted U falls down, and out of the patient's field of vision. The procedure is done to improve the vision of a patient with a secondary cataract. What CPT® code is reported?

66821-RT Rationale: In the CPT® Index look for Cataract/Incision/Laser. Documentation states that this is performed on a secondary cataract with a laser. The cataract is not removed from the eye, just from the line of vision. The cutting or incision through a part is a dissection. The procedure is described by code 66821. Modifier RT is used to indicate the procedure was 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?

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 with aphakia and anisometropia in the right eye undergoes surgery to implant a lens. An incision is made in the corneal-scleral juncture and a scleral tunnel is made. A partial vitrectomy is performed and the provider guides the intraocular implant into the eye pulling it into position by Prolene sutures. What CPT® code is reported?

66985-RT Rationale: Code 66985 is the correct code since the insertion of lens is for aphakia (not associated with cataract). In the CPT® Index look for Intraocular Lens/Insertion/Not Associated with Concurrent Cataract Removal.

A provider uses cryotherapy for removal trichiasis of the right upper eyelid. What CPT® and ICD-10-CM codes are reported?

67825-E3, H02.051 Rationale: In the CPT® Index, look for Trichiasis/Repair/Epilation, by Other than Forceps. Verify this code in the numeric section. Code 67825 describes the correction of trichiasis by other than forceps, for example cryotherapy. HCPCS Level II modifier E3 indicates Upper right eyelid. In the ICD-10-CM Alphabetic Index look for Trichiasis (eyelid)/right/upper directs you to code H02.051 and is verified in the Tabular List as Trichiasis without entropion right upper eyelid.

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?

67904-E1 Rationale: In the CPT® Index look for Blepharoptosis/Repair/Tarso Levator Resection/ Advancement/External Approach. You are referred to 67904. Review the code in the numeric section to verify accuracy. This is the correct code because the external approach of cutting the skin of the eyelid was performed and dissection is carried to the levator tendon. The provider uses sutures to advance the levator tendon to create a new eyelid crease. Append modifier E1 for Upper left, eyelid.

The patient was taken to the operating room. The provider everts the upper eyelid and places clamps across the everted undersurface of the upper lid. The tissue distal to the clamps is excised or resected. This tissue includes conjunctiva, tarsus, Muller's muscle and the distal insertion of the levator aponeurosis. The remaining tissue is reattached and sutured. What CPT® code is reported?

67908 Rationale: This is a repair of blepharoptosis. In the CPT® Index, look for Blepharoptosis/Repair directs you to code range 67901-67909. The codes are selected based on the approach and technique. After verifying in the numeric section, code 67908 is the correct code.

A 65 year-old patient presents with an ectropion of the right lower eyelid. Repair with tarsal wedge excision is performed for correction. Attention was then directed to the left eye. The patient also has an ectropion of the left lower eyelid which is repaired by suture repair. What CPT® code(s) is/are reported?

67916-E4, 67914-E2 Rationale: In the CPT® Index look for Ectropion/Repair/Excision Tarsal Wedge which directs you to code 67916. Then further down in the same list Suture directs you to 67914. Modifier E4 is appended to 67916 to show it was performed on the right lower eyelid. Modifier E2 is appended to 67914 to show it was performed on the left lower eyelid.

Patient had an abscess in the external auditory canal which was incised and drained in the office. What CPT® code is reported?

69020 Rationale: In the CPT® Index, look for Abscess/Tissue/Auditory Canal, External/Incision and Drainage which directs you to 69020. Verify in the numeric section that code 69020 is the appropriate code for drainage of an abscess located in the external auditory canal of the ear. For this procedure, the provider makes an incision in the skin and drains the external auditory canal abscess.

A 12 year-old male patient has an abscess located at the external auditory meatus. The ENT incises the abscess and packs it to absorb the drainage. What CPT® code is reported?

69020 Rationale: The external auditory meatus is also referred to as the external auditory canal which starts from the opening of the ear to the eardrum. If you look in the CPT® Index under Ear Canal it refers you to See Auditory Canal. Look up Auditory Canal/External/Abscess/Incision and Drainage which guides you to codes 69000, 69005 and 69020. Verify the correct code in the numeric section. 69020 is the correct code for an abscess of the auditory canal. The other codes refer only to the external ear.

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?

69420, H68.012 Rationale: In the CPT® Index look for Myringotomy and you are directed to 69420-69421. Verify the code in the numeric section. In the ICD-10-CM Alphabetical Index, look for Salpingitis/eustachian (tube)/acute and you are directed to H68.01-. Verification in the Tabular List indicates a 5 th character is needed for laterality. 5 th character of 2 for the left ear.

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?

69436-RT, H65.21 Rationale: In the CPT® Index look for Tympanostomy/General Anesthesia directing you to 69436, then verify the code in the numeric section. Code 69436 is the correct code to report because a small incision is made in the tympanum, the fluid in the middle ear is suctioned, and an insertion of a small ventilating tube is placed into the opening of the tympanum under general anesthesia. Modifier RT is appended to indicate the side of the body the procedure was performed. In the ICD-10-CM Alphabetical Index look for Otitis/media/chronic/serous which states see Otitis, media, nonsuppurative, chronic, serous. Look for Otitis/media/nonsuppurative/chronic/serous directing you to H65.2. The Tabular List indicates a 5 th character is needed to show laterality. 5 th character 1 is for the right ear.

A patient with mixed conductive and sensorineural hearing loss in the right ear has tried multiple medical therapies without recovery of her hearing. Patient has consented to have an electromagnetic bone conduction hearing device implanted in the temporal bone. What CPT® and ICD-10-CM codes are reported?

69710-RT, H90.71 Rationale: In the CPT® Index look for Hearing Aid/Implants/Bone Conduction/Implantation. You are referred to 69710. Review the code to verify accuracy. In the ICD-10-CM Alphabetical Index look for Loss (of)/hearing which states see also Deafness. Look for Deafness/mixed conductive and sensorineural/unilateral. You are referred to H90.7-. Review the code in the Tabular List to verify accuracy and 5 th character 1 is for right ear.

What ICD-10-CM code is reported for left lower eyelid basal cell carcinoma?

C44.1192 Rationale: Look in the ICD-10-CM Alphabetic Index for Carcinoma/basal cell. You are directed to see Neoplasm, skin, malignant. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/skin/eyelid/basal cell carcinoma and select the code from the Malignant Primary column directing you to C44.11-. A 6 th character of 9 specifies the left eyelid. A 7th character 2 is reported for the lower eyelid.

What is the transparent part of the eye?

Cornea Rationale: The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber.

A patient has heavy skin and muscle (myogenic) that is drooping down and blocking his vision due to myogenic ptosis of the upper eyelid. The provider performed a bilateral upper blepharoplasty. What ICD-10-CM code(s) is (are) reported?

H02.423 Rationale: Drooping (ptosis) of the upper eyelid is due to a muscle disorder (myogenic). In the ICD-10-CM Alphabetical Index look for Ptosis/eyelid which states to see Blepharoptosis. Look for Blepharoptosis/myogenic and you are directed to H02.42-. Tabular List indicates 6 th character is needed to indicate laterality. 6 th character of 3 is for bilateral. Only one code is reported for both eyelids, not two separate codes.

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

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 is the abbreviation for EACH EYE?

O.U. Rationale: O. U. stands for each eye or both eyes. O.D. stands for the right eye. O.S. stands for the left eye.

A surgeon performed a cataract extraction with an intraocular lens implant on the right eye of a Medicare patient. What modifier(s) would be reported?

RT Rationale: Modifiers RT and LT are used to identify procedures performed on paired organs such eyes, ears, breasts (excluding skin) or on sides of the body.