Scleral buckling, a treatment for retinal detachment, uses an explant or an implant to indent, or "buckle" inward, the sclera, closing any holes or tears. These "buckles" are made of materials such as silicone rubber or fascia lata.
When an infection causes a buckle to extrude, it can be irritating to the patient. To code for the complication, you have two choices: 996.59 (Complications peculiar to certain specified procedures; due to other implant and internal device, not elsewhere classified) or 996.69 (Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft), depending on the documentation.
The appropriate procedure code is difficult to identify because, as with the ICD-9 codes, there is no specific mention of a scleral buckle in the descriptor of the applicable code. To choose the correct CPT code, you need to know that the scleral buckle is material implanted in the posterior segment of the eye, typically after a retinal tear has been treated by a burn, sealing the choroids to the retina. This description of a buckle will lead you to code 67120 (Removal of implanted material, posterior segment; extraocular).
For example, you could use 361.00 (retinal detachment with retinal defect, unspecified), or 361.02 (recent detachment, partial, with multiple defects). But you should always use one of the retinal detachment codes, since that is the condition that caused the buckle to be placed. You also should use one of the complications diagnosis codes, such as 996.59 (complications peculiar to certain specified procedures; due to other implant and internal device, not elsewhere classified).
Another code that applies is 996.69 (infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to other internal prosthetic device, implant, and graft). There is no specific diagnosis code for removal of a scleral buckle. When choosing the diagnosis codes, look at the primary reason why the procedure is being done as the primary diagnosis.
Insertion of radioactive plaques (67218) for the treatment of choroid melanoma(190.6)--V10.84 for Hx
379.91 for pain in eye