CPC Chapter 15- Eye and Ocular Adnexa, Auditory Systems Practical Flashcards
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?
67107
H33.021
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?
68811-50
H04.553
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?
69300-50
Q17.5
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?
69205-RT
T16.1XXA
CASE 5
PREOPERATIVE DIAGNOSIS:
- Cataract, right eye.
POSTOPERATIVE DIAGNOSIS:
- Cataract, right eye.(The postoperative diagnosis is used for coding.)
PROCEDURE:
- Complex phacoemulsification with manual stretch of the iris, right eye.
- 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?
66982-RT
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?
66984-LT
H26.9
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 OPERATIVE 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?
69620-RT
H72.01, H90.11, H74.01
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?
69660-RT, 21235-51-RT
H80.81
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?
42830, 69436-50-51
J35.2, H65.93
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?
15260-E2, 67966-51-E2
67971-51-E2, 67875-51-E1-E2
C44.1192
