louise Posted Mon 20th of May, 2019 12:11:28 PM
Diagnosis: IOL dislocation; RIGHT eye
IOL removal from anterior approach, IOL removal pars plana approach with limited pars plana vitrectomy
A lid speculum was placed and the operating microscope . A 6.0mm peritomy was made superiorly. Using a crescent blade, a 6mm scleral tunnel corneal incision was made into the anterior chamber. Two paracentesis wound were made at 5 and 9 o'clock. An anterior chamber maintainer was placed in the 5 oclock paracentesis wound. Using lens scissors through the superior wound and serrated forces through the temporal paracentesis wound, the lens was cut 80% across its middle and gently externalized through the main wound. Once half was cut all the way through and removed safely out of the eye.
remove the second half of the IOL from a pars plana approach. Two 25 gauge trocars were placed superotemporally and superonasally. Using back flush the IOL was aspirated anteriorly and explanted through the superior scleral incision. Scleral depression was performed to inspect the retina and no tears or holes were noted. A gentle limited core vitrectomy was performed. .
SuperCoder Answered Tue 21st of May, 2019 07:03:05 AM
As per the above-mentioned report, the appropriate CPT codes will be 65920, 66852, 66990. CPT 66930 is not an appropriate code because as per the clinical responsibility of CPT 66930, the provider removes the complete lens along with the surrounding capsule due to a partial or complete dislocation of the lens. But in given report, surgeon is removing second half of IOL via pars plana approach for which the appropriate code will be 66852.