Coding Procedures of the Eye, Ocular Adnexa System


Vol. 14 •Issue 10 • Page 15
Coding Corner

Coding Procedures of the Eye, Ocular Adnexa System

Case Study 1

Preoperative Diagnosis: Fuchs’ corneal endo-thelial dystrophy, right eye

Postoperative Diagnosis: Fuchs’ corneal endo-thelial dystrophy, right eye

Procedure Performed: Corneal transplant, right eye, 8.0 mm into 7.5 mm

Anesthesia: Retrobulbar with MAC

Indications for Procedure: This patient is pseudophakic in her right eye and has Fuchs’ corneal endothelial dystrophy. The cornea has swollen significantly to impair her vision. After the risks, benefits, alternatives and complications of penetrating keratoplasty were explained to her, she decided she would like to proceed with the operation.

Operative Technique: The patient was brought to the pre-operative holding area. IV sedation was obtained. After monitoring equipment was placed on the patient by anesthesia, a retrobulbar anesthetic block using a 0.75% Narcaine with 2% Lidocaine was given.

A Honan balloon was placed on the eye for approximately 12 minutes. The patient was then given a modified O’Brien anesthetic block to the lid. A wire lid speculum was used to expose the globe. Next, the center of the cornea was marked. An 8.0 mm trephine was then used on the donor cornea and set aside.

Attention was then turned to the patient’s cornea, which was edematous and cloudy. A 7.5 mm Katena trephine was used. Occucoat was placed in the anterior chamber. The donor cornea was then placed on the eye and sewn into place using #12 interrupted 10-0 nylon suture. The wound was checked for leaks, and none were found. The patient was given subconjunctival, Gentamycin and Depo-Medrol. Her eye was patched.

She was taken to the recovery room in good condition. There were no complications.

ICD-9-CM Code Assignments

Preoperative Diagnosis: Fuchs’ corneal endothelial dystrophy, right eye

371.57 Endothelial corneal dystrophy

Postoperative Diagnosis: Fuchs’ corneal endothelial dystrophy, right eye

371.57 Endothelial corneal dystrophy

CPT Code Assignments

The surgeon states that this patient is pseudophakic with the Fuchs’ dystrophy, which has impaired her vision. To repair the corneal dystrophy, a donor cornea was transplanted to the patient’s cornea after the edematous cornea was removed.

To assign the code for the procedure, look in the CPT manual index under the term Keratoplasty, followed by the terms Penetrating then in Pseudophakia. You will see after reading this code description that the correct code is 65755 for both the facility and professional coding. You would also assign modifier RT (right side of the body) when facility coding.

Facility Code Assignment

65755-RT Keratoplasty (corneal transplant); penetrating (in pseudo-phakia)

Professional Code Assignment

65755 Keratoplasty (corneal transplant); penetrating (in pseudo-phakia)

Case Study 2

Preoperative Diagnosis: Intermittent alternating exotropia

Postoperative Diagnosis: Intermittent alternating exotropia

Procedure Performed: Bilateral lateral rectus recessions of 7.5 mm

Anesthesia: General

Operative Technique: The patient was taken to the operating room and placed under general anesthesia in the supine position. The eyes were then prepped and draped in the usual manner for ocular surgery.

A lid speculum was inserted in the right eye. Forced ductions were performed, and no restrictions were found. A 4-0 black silk suture was placed in the 6 and 12 o’clock positions. The eye was rotated, medially exposing the lateral rectus area. A limbal periotomy was performed with a superior relaxing incision.

The lateral rectus muscle was then isolated on the muscle hook and freed of its attached Tenon’s at the intermuscular membrane. Two double-armed 6-0 Vicryl sutures were then passed at the superior and inferior borders of the muscle and tied. The muscle was then dis-inserted and then re-inserted at the sclera by 7.5 mm from the original insertion. The conjunctiva was re-positioned and sutured with 8-0 Vicryl. The identical procedure was performed on the left side.

Tobradex ointment was instilled in both eyes, and the patient left the operating room in satisfactory condition.

ICD-9-CM Code Assignments

Preoperative Diagnosis:.Intermittent al-ternating exotropia

378.24 Intermittent exotropia, alternating

Postoperative Diagnosis:.Intermittent alternating exotropia

378.24 Intermittent exotropia, alternating

CPT Code Assignments

The surgeon states that the lateral rectus muscle in each eye was recessed or weakened to correct the exotropia. To assign the CPT code for this procedure, refer to the term Strabismus in the CPT manual index. This is followed by the terms Repair and One Horizontal Muscle.

After reading the code description you will see that code 67311 is the correct code for both the facility and professional code assignment. In both cases, modifier 50 is assigned to show that this was a bilateral procedure.

Facility Code Assignment

67311-50 Strabismus surgery, recession or resection procedure; one horizontal muscle

Professional Code Assignment

67311-50 Strabismus surgery, recession or resection procedure; one horizontal muscle

Susan Howe is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.

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