Ch. 15: Eye and Ocular Adnexa, Auditory Systems

Question 1

What is the abbreviation for EACH EYE?

Answer 1

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

Question 2

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

Answer 2

a. E11.3219
Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Diabetes/type 2/with/retinopathy/nonproliferative/mild/with macular edema and you are directed to E11.321-. The Category E11.- indicates the type of diabetes. Since the type is not indicated, the default is type 2 per ICD-10-CM guideline I.C.4.a.1. Verify code selection in the Tabular List. The code requires a 7 th character to identify the eye involved. Because the laterality of the eye is not indicated in the question, use the 7 th character 9 for unspecified eye.

Question 3

What does IOL stand for?

Answer 3

a. Intraocular lens
Response Feedback:
Rationale: IOL stands for intraocular lens.

Question 4

What ICD-10-CM code is used to report acute actinic otitis externa of the left ear?

Answer 4

b. H60.512
Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Otitis/externa/acute/actinic and you are directed to H60.51-. Verification in the Tabular List indicates a 5 th character is reported for laterality. 5 th character of 2 is for left ear.

Question 5

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

Answer 5

b. H26.9
Response Feedback:
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.

Question 6

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?

Answer 6

d.
H02.423

Response Feedback:
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.

Question 7

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

Answer 7

c.
69200

Response Feedback:
Rationale: In the CPT® Index look for Auditory Canal/External/Removal/Foreign Body which directs you to code range 69200-69205. Verify the code in the numeric section. Code 69200 is the appropriate code for the removal of a foreign body from the external auditory canal without general anesthesia. Code 69205 is with anesthesia. Under direct visualization the foreign body is removed from the external auditory canal using delicate forceps, a cerumen spoon or suction. No anesthetic or local anesthetic is used.

Question 8

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?

Answer 8

d.
69300-50

Response Feedback:
Rationale: In the CPT® Index look for Otoplasty which directs you to code 69300 and is confirmed by the code description in the Auditory System numeric section. The parenthetical note beneath 69300 instructs us to report the code with modifier 50 for a bilateral procedure.

Question 9

A patient with a cyst like mass on his left external auditory canal was visualized under the microscope and a microcup forceps was used to obtain a biopsy of tissue along the posterior superior canal wall. What CPT® code is reported?

Answer 9

d. 69105-LT
Response Feedback:
Rationale: In the CPT® Index look for Auditory Canal/External/Biopsy. Verify in the CPT® numeric section. Code 69105 with modifier LT is correct since the biopsy was taken from the left ear in the auditory canal.

Question 10

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?

Answer 10

d. 66984-RT
Response Feedback:
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.

Question 11

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

Answer 11

d. 69636-RT
Response Feedback:
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.

Question 12

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?

Answer 12

d. 67916-E4, 67914-E2
Response Feedback:
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.

Question 13

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?

Answer 13

d. H26.9
Response Feedback:
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.

Question 14

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?

Answer 14

d. 69420, H68.012
Response Feedback:
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.

Question 15

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?

Answer 15

b. 66985-RT
Response Feedback:
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.

Question 16

Preoperative Diagnosis: Left orbital cyst, hemangioma versus lymphangioma
Postoperative Diagnosis: Left orbital cyst, hemangioma versus lymphangioma
Procedures Performed: Aspiration of left orbital cyst with injection of Kenalog
Anesthesia: General
Complications: None
Estimated Blood Loss: Minimal
Indications for Procedure: The patient presents with a small cyst of the superior medial left orbit felt to be suggestive for hemangioma versus lymphangioma. Risks, benefits, and alternatives of steroid injection to inactivate the cyst were reviewed. These risks included failure to work and significant visual loss. After discussion, they elected to proceed.
Description of Procedure: After informed operative consent was obtained, the patient was brought to the operating room and laid in the supine position. General anesthetic was administered per the anesthesiologist. A 25-gauge needle on a 5 cc syringe was placed within the mass and aspirated. Approximately 0.5 cc of blood was recovered, but the blood was of normal bright red color.
Kenalog 40 mg (1 cc) was then injected where the mass was aspirated without difficulty. Operative area was clean and dry. The patient was then awakened and taken to the recovery room. Pupil reactions were brisk and equal with 2 mm pupils noted in the recovery room. There were no operative complications. What are the procedure and diagnosis codes?

Answer 16

d.
67415-LT, H05.812

Response Feedback:
Rationale: The provider aspirated a cyst that was in the left orbit. In the CPT® Index look for Aspiration/Orbital Contents referring you to code 67415. Code 67500 is reported when there is an injection of a therapeutic or local anesthetic behind the eyeball (retrobulbar). Diagnoses documented as versus are not definitive diagnosis codes and are not coded. The postoperative header indicates an orbital cyst. In the ICD-10-CM Alphabetical Index look for Cyst/orbit referring you to code H05.81-. Verify code in the Tabular List. A 6 th character is required to indicate which eye; 2 is reported for the left eye.

Question 17

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?

Answer 17

d. 66711
Response Feedback:
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.

Question 18

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?

Answer 18

c. 66821-RT
Response Feedback:
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.

Question 19

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?

Answer 19

b.
67113, H33.031, W21.03XA

Response Feedback:
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.

Question 20

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

Answer 20

b. 67808-E1-E3, H00.11, H00.14
Response Feedback:
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.

Question 21

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

Answer 21

a.
67825-E3, H02.051

Response Feedback:
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.

Question 22

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?

Answer 22

c. 67010
Response Feedback:
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.

Question 23

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?

Answer 23

b. 65103-LT, S05.22XA, V49.59XA, Y92.411
Response Feedback:
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.

Question 24

A provider extracts a tumor, using a frontal approach, from the lacrimal gland of a 14 year-old patient. What CPT® and ICD-10-CM codes are reported?

Answer 24

a. 68540, D49.89
Response Feedback:
Rationale: In the CPT® Index look for Lacrimal Gland/Tumor/Excision/Frontal Approach directs you to 68540. This code is used to describe the excision for a lacrimal gland tumor using the frontal approach. In ICD-10-CM Alphabetical Index look for Tumor directing you to see also Neoplasm, unspecified behavior, by site. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/ lacrimal/gland and select the code from the Unspecified Behavior column. Verify code selection in the Tabular List.

Question 25

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?

Answer 25

a. 65780
Response Feedback:
Rationale: In the CPT® Index look up Transplantation/Eye/Amniotic Membrane. You are referred to 65778-65780. Verify in the numeric section. Code 65780 is the correct code because the amniotic membrane transplantation is for an ocular surface reconstruction for corneal defects of scarring and perforation.