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Code This!

Scenario Week of December 20, 2012:
View Current Scenario

Assign the Correct ICD-9-CM and ICD-10-CM Diagnosis and CPT 2013 Procedure Codes for the Following Outpatient Coding Scenario.

Preoperative Diagnosis: Nuclear sclerotic and cortical cataract, right eye

Postoperative Diagnosis: Same

Operation: Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye

Procedure: Patient was taken to the operating room and placed on the table in the supine position with identification and operative site confirmed. Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Hydase with 6 cc of this solution used in a peribulbar injection, followed by 10 minutes of digital massage. The patient was then prepped and draped in the usual sterile fashion for eye surgery. With the operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridle suture placed in the superior rectus muscle. Using Westcott scissors, a fornix-based conjunctival flap was made. The surgical limbus was identified and hemostasis obtained with wet-field cautery. A corneoscleral groove was made with a 57-Beaver blade, and shelved into clear cornea. A stab incision was made at 2 o’clock with a 15-degree blade. With a 3.0 mm keratome, the shelved groove was placed into the anterior chamber. Viscoelastic was inserted into the anterior chambers and an anterior capsulotomy was performed in a continuous-tear technique.

Hydrodissection was performed with Balanced Salt Solution. Phacoemulsification was performed in a two-headed nuclear fracture technique. The remaining cortical material was removed with irrigation and aspiration handpiece. The posterior capsule remained intact and vacuumed with minimal suction. The posterior chamber intraocular lens was obtained. It was inspected, irrigated, and inserted into the posterior chamber without difficulty. Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound. There was no aqueous leak even with digital pressure. The conjunctiva was pulled back into position with wet-field cautery. A subconjunctival injection with 20 mg Gentamicin and 0.5 cc Celestone was given. TobraDex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture. The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in my office tomorrow.

Code This! Assign the correct ICD-9-CM and ICD-10-CM Diagnosis and CPT 2013 Procedure Codes.


ICD-9-CM Diagnosis Codes
366.16 Senile cataract, nuclear sclerosis

CPT Procedure Codes
66984-RT Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); right side

ICD-10-CM Diagnosis Codes
H25.11 Age-related nuclear cataract, right eye

Rationale
ICD-9-CM:
In the alphabetic index, the term “cortical” is a nonessential modifier for cataract; therefore, the only subterm look-up for this diagnosis is “nuclear,” which is 366.16. The tabular index confirms nuclear sclerosis under the category for senile cataract.

CPT 2013: The CPT index for Cataract, Removal/Extraction, Extracapsular cites two codes: 66982 and 66984. Upon review in the Eye and Ocular Adnexa chapter, under “Intraocular Lens Procedures,” code 66984 is selected. Note that insertion of intraocular lens prosthesis is integral as seen in the full description of the procedure. There is an instructional note related to insertion of ocular telescope prosthesis, which does not apply to this scenario.

ICD-10-CM: In the alphabetic index, the term “cortical” is a nonessential modifier for cataract; the subterm nuclear, sclerosis instructs to “see Cataract, senile, nuclear,” which is H25.1- , the hyphen indicating additional characters are needed. The tabular index shows that the complete code is H25.11 for Age-related nuclear cataract, right eye.

Note: HIPPA mandates that ICD-9-CM volume 3 codes are only used for inpatient services on medical claims. CMS stated volume 3 codes may be used for internal tracking purposes, but the HIPPA standard is to use HCPCS (CPT/HCPCS) codes in all other (outpatient) settings for procedure coding. This will also apply when ICD-10-PCS goes into effect.

 
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