Chapter 15
What ICD-10-CM code is reported for an encounter for cataract screening?
Z13.5
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
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
Today we excised bilateral recurrent pterygiums under topical anesthetic. The conjunctival incisions were repaired simply. What CPT® code is reported for this procedure?
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.
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?
65780
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
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 right and left prominent ears presents for an otoplasty. What CPT® and ICD-10-CM codes are reported?
69300-50, Q17.5
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?
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.
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?
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.
What CPT® code is used to report surgery to remove an aqueous shunt from the patient's extraocular posterior segment of the eye?
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.
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?
67311, 67332
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?
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.
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
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?
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.
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?
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.
What CPT® code is reported for removal of foreign body from the external auditory canal without general anesthesia?
69200
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?
69300-50
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?
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 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
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
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?
69631-LT
What CPT® code is reported for a tympanoplasty with mastoidotomy and with ossicular chain reconstruction in the right ear?
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.
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?
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 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?
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.
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?
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.
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).
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?
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.
The pathology report comes back and the tumor is a malignant acoustic schwannoma. What is the correct diagnosis code?
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 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).
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.
What ICD-10-CM code is reported for mild nonproliferative diabetic retinopathy with macular edema?
E11.3219
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?
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.
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?
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.
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?
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.
What ICD-10-CM code is reported for bilateral chronic otitis media with effusion?
H65.493
What ICD-10-CM code is reported for suppurative otitis media in the right ear?
H66.41
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?
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.
What does IOL stand for?
Intraocular lens
Which of the following has NO refractive properties?
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.
What is the abbreviation for EACH EYE?
O.U.
What is exophthalmos?
Protrusion of the eyeballs.
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?
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.
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.
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.
What is a blepharoplasty?
Surgical repair of the eyelid. RATIONALE: Blephar/o is a root word identifying the eyelid, and plasty indicates a surgical repair.
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.
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 incus bone is between the malleus and the stapes. In which part of the ear is the incus located?
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.
What occurs in myringotomy?
The tympanic membrane is incised. RATIONALE: Myring/a is a root word identifying the tympanic membrane and -otomy is a suffix indicating an incision.
