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Scenario Week of June 07, 2011:
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Indication: 3-year-old with history of lazy eye for the past two years. Patient has been treated with alternative methods without success. The risks and benefits of surgery have been explained to the parents and after careful consideration they have consented to surgical treatment.

Procedure: The patient was taken to the operating suite. After induction of general anesthesia, the patient was prepped and draped. A speculum was placed in the left eye. An incision was made in the conjunctiva at the limbus. The medial rectus muscle was isolated with a muscle hook. The medial muscle was resected. The medial muscle was reattached to the sclera by adjustable sutures. Attention was then turned to the lateral rectus muscle. The procedure was repeated. A single 10-0 Nylon suture was placed. Tobradex ointment was instilled into the left conjunctival sac and a firm patch placed on the left eye. The patient tolerated the procedure well and was sent to recovery in satisfactory condition.

CPT Coding

67312–LT Strabismus surgery, recession or resection procedure; 2 horizontal muscles

67335–LT Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s)

ICD-9-CM Coding

378.9 Unspecified disorder of eye movements

CPT Rationale

The patient had two horizontal muscles resected: the medial rectus and the lateral rectus. CPT strabismus coding is based first on the number of muscles, and then in which direction the muscles are attached, horizontal or vertical. There were two muscles, horizontally attached, reported by 67312. Also, the physician used adjustable sutures, so it would be appropriate to report an add-on code for those: 67335. Modifier LT should be appended to the procedures to indicate that they were performed on the left side.

ICD-9-CM Rationale

Little information is given about the patient’s diagnosis; however, the pre- and postoperative diagnosis of strabismus has been documented. “Strabismus” in the ICD-9-CM index leads to the unspecified code 378.9 Unspecified disorder of eye movements. The coder may wish to query the provider for the most detailed diagnosis for this patient. There are also indications in the documentation that the patient has a history of “lazy eye” (amblyopia) as well, but there may be medical necessity issues with either of these diagnoses from a payer perspective.

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