Question

Surgery Case-019

week 5 Surgery for Outpatient

assign CPT and ICD-10-CM codes

LOCATION: Inpatient, Hospital PATIENT: Pete Sharp SURGEON: Rita Wimer, M.D. PREOPERATIVE DIAGNOSES: 1. Cataract, left eye. 2. Excess myopia, both eyes. 3. Hypertension. 4. Diabetes mellitus, diet controlled. 5. Anxiety. 6. Hyperlipidemia POSTOPERATIVE DIAGNOSES: Same. PROCEDURE PERFORMED: Simple Extracapsular cataract extraction, left eye, with insertion of posterior chamber lens implant, left eye for calcification of lens. ANESTHESIA: General. INDICATIONS: This 49-year-old male has had vision decrease in his left eye to the 20/70 20/80 range and 20/40 in the right eye. This is secondary to calcification of lens (cataract) in the left eye greater than the right eye. This is now threatening his ability to maintain a commercial driving license. The patient was counseled for surgery, the risks of anesthesia, infection, hemorrhage, the 1 in 20,000 chance of blindness and the fact that we would be setting him at zero refraction despite his excess myopia in preparation for the other eye to be done. Because of the patient's anxiety level, it was elected to do this under general anesthesia. The patient also had a 27.25 mm eyeball which requires general anesthesia or topical. PROCEDURE: After the patient was placed under suitable general endotracheal anesthesia, the left eye was prepped and draped in the usual sterile fashion for ophthalmic surgery. A wire lid speculum was used to separate the lids of the left eye and a lateral canthotomy was performed. Fornix-based flap was raised from 3 o'clock to 9 o'clock and a 4-0 silk suture was used anterior to the superior rectus muscle for retraction purposes. The wet-field cautery was used and a 69 Beaver blade made a 1/2 thickness lamellar groove from 9:30 to 2:30 and the super knife was used to enter the eye at 11 o'clock. The chamber was filled with Healon and a dry non-irrigating anterior capsulotomy was performed on a bent 25 gauge Surgery Case-019 2 | P a g e needle. The wound was extended with left and right going corneal cutting scissors and three 8-0 Vicryl sutures were post placed. Using the lens vectis non-irrigating, the nucleus was expressed with some counterpulsion at 6 o'clock intact and without iris prolapse. Post placed sutures were tied down. The Simcoe I&A apparatus was used to clean up excess cortex and polish the capsule. The chamber was then filled with Healon and the curved tying forceps placed at 12 diopter easy-E-70 lens in the bag and it was dialed horizontally with the Satinsky lens hook. Miochol was used to bring down the pupil and nine, 10-0 nylon sutures were used to close the wound. Two, 8-0 Vicryl sutures were used to close the conjunctiva and 8 mg of Decadron were injected subtenons inferiorly. Pilopine gel, Maxitrol ointment, a Telfa pad, patch and shield was applied and the patient sent to the recovery area. There were no complications.

Answer 1

Ans) CPT - current procedure terminology.

ICD - 10 - CM It is divided into ranges based on the type of injury or disease they document.

Definitions: International classification of disease ,Tenth Revision,clinical modification.It is system used by physician and other Health care providers to classifyand code all diagnosis,symptoms and procedures recorded in conjunction with hospital care in US.

Z98.4 - cataract extraction status.

H25.11 - age related nuclear cataract,left eye.

66821 - yag capsulotomy. Code c6821.

H26.492 -other secondary cataract,left eye.

188.53xD - unilateral general anaesthesia during procedure.

024.93 - -diabetes.

F41.1. - anxiety.