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Cortex removal

Shamae Posted Tue 24th of June, 2014 11:17:08 AM

We had a patient last week for a cataract removal with IOL. In their follow up appointment with the physician it was discovered there is still some cortex left over and will be returning to us for a procedure to remove what is left. In between us as the surgical center and the physician's we are uncertain on how to bill this procedure on CPT and diagnosis code. The closes we were able to find for diagnosis was 366.23 but this is not a trauma or 366.8 but still is not a calcification. Nor is this a 66982 or a 66984 for CPT.

SuperCoder Answered Wed 25th of June, 2014 09:14:35 AM

Thank you for your question.

Without knowing the technique the physician is using to go back in and remove the material, I would suggest a review of the following codes:
66840: Removal of lens material; aspiration technique, 1 or more stages
66820:Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) (66821 is laser technique)

If the IOL needed to be repositioned at all: 66825; Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure)

366.23 would be the diagnosis I suggest. Traumatic is a term used to describe the trauma to the eye, not necessarily meaning an external traumatic cause.

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