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Scenario Week of March 29, 2013:
View Current Scenario

Assign the Correct ICD-9-CM Diagnosis and ICD-10-CM/PCS Diagnosis and Procedure Codes for the Following Coding Scenario.

Preoperative diagnosis: Exotropia

Postoperative diagnosis: Exotropia

Procedure: Bilateral lateral rectus recession

Anesthesia: General endotracheal

The patient was brought to the operating room, prepped, and draped in the usual manner for strabismus surgery. The specula were placed in the fornices of both eyes, and four sections were done, revealing no restrictions. Attention was then turned to the right eye and a wet 4 X 4 covered the left. A #4-0 silk bridle suture was placed at the vertical limbi, and the eye was placed in adduction. Surgical marking pen was used to denote the quadrants, and Wescott scissors were used to do a lateral peritomy. The quadrants were blunt dissected with Wescott scissors, and a Graefe hook was placed underneath the lateral rectus muscle and replaced with a Jameson hook. Stevens hooks were used to retract conjunctive and tenons away from the muscle, which was then sharply dissected away close to the muscle.

Hemostasis was achieved with bipolar cautery. Double armed #6-0 Vicryl suture was placed through each pole of the muscle, and the muscle was excised from the globe with Aebli scissors. The muscle was reattached 6 mm back from the original insertion site and also was transposed superiorly half a muscle width superior. The conjunctiva was reapproximated with #7-0 Vicryl. Attention was then turned to the left eye, and the exact same procedure was done. The patient tolerated the procedure well, and there were no complications.

Assign the appropriate ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes, as appropriate:


ICD-9-CM Diagnoses:
378.10 Exotropia, unspecified

ICD-9-CM Procedures:
15.11 Recession of one extraocular muscle
15.11 Recession of one extraocular muscle

Because the specific type of exotropia is not specified, code 378.10 Exotropia, unspecified, must be assigned. For the bilateral procedure, the code for recession of one extraocular muscle (15.11) must be assigned twice. Refer to Coding Clinic, third quarter 1996, page 3: “Assign code 15.11 Recession of one extraocular muscle, twice, for the procedure performed. Code 15.11 is assigned since the operation is on only one muscle in each eye. Code 15.3 is assigned only if the procedure is performed on two or more muscles in one or both eyes.”

ICD-10-CM Diagnosis Code :
H50.10 Unspecified exotropia

ICD-10-PCS Procedure Codes:
08SL0ZZ Reposition Right Extraocular Muscle, Open Approach
08SM0ZZ Reposition Left Extraocular Muscle, Open Approach

There is an instructional note in the alphabetic index under “Exotropia” that refers the user to “see Strabismus, divergent concomitant.” This entry routes the user to H50.10 Unspecified exotropia. Because there is no further documentation involving the type and pattern involved, the unspecified code must be assigned. For the ICD-10-PCS procedure, the intent of the procedure is to move the position of the extraocular muscles; root operation Reposition is assigned. Because there is no body part character for bilateral extraocular muscles, two codes must be assigned, one for each extraocular muscle, right and left. The approach is open, and there are no devices or qualifier characters.

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