Billings Community Education Online Medical Classes | Advanced Medical Coding Chapter 13
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Advanced Medical Coding Chapter 13

06 Aug Advanced Medical Coding Chapter 13

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Advanced Medical Coding Chapter 13
Question 1 of 6
Question #1: OPERATIVE REPORT, CATARACT EXTRACTION AND LENS IMPLANT
LOCATION: Outpatient, Hospital
PATIENT: Ray Shaw
ATTENDING PHYSICIAN: Rita Wimer, MD
PREOPERATIVE DIAGNOSIS: Cataract, OD (right eye)

POSTOPERATIVE DIAGNOSES:

Cataract, OD (right eye).
Scleral malacia, OD (right eye).

PROCEDURE PERFORMED: Extracapsular cataract extraction, OD (right eye), with insertion of posterior chamber lens implant, OD (right eye)
ANESTHESIA: MAC
INDICATIONS: This 67-year-old white male has had decreased vision of his right eye to the range of 20/80 where he cannot see down the road anymore. He has a dense nuclear sclerotic senile cataract on the right eye, which is precluding good vision. The rest of the eye was normal. He was counseled for cataract surgery, the need for postoperative correction, the 4- to 6-week recovery time, the type of procedure, and the risk of blindness at the rate of 1 in 20,000.
DESCRIPTION OF PROCEDURE: After the patient was placed on the OR (operating room) table, he was given Nadbath and Van Lint anesthesia on a 25-gauge needle for a volume of 9 cc (cubic centimeter). Xylocaine 2% with 0.75% Marcaine and Wydase was used. The same mixture was administered on a retrobulbar needle, 23-gauge, for a volume of 3.5 cc without complication. The Honan balloon was inflated to 35 mmHg (millimeters of mercury) for 3 minutes by the clock. After this, the patient was prepped and draped in the usual sterile fashion for ophthalmic surgery, and a wire lid speculum was used to separate the lids of the right eye. A fornix-based flap was raised from 3 o'clock to 9 o'clock, and a 4-0 silk suture was placed under the insertion of the superior rectus muscle for retraction purposes. The wet-field cautery was used, a #69 Beaver blade made a half-thickness lamellar groove from 9:30 to 2:30, and the Super knife was used to enter the eye at 11 o'clock. The chamber was filled with Healon, and a dry, nonirrigating anterior capsulotomy was performed on a bent 25-gauge needle. It was noted that the patient had marked scleralomalacia, but there was no dehiscence. The sclera was quite thin. After the capsulotomy was performed, post-placed sutures were placed after the left- and right-going corneal cutting scissors were used. The lens vectis was used to express the nucleus without capsular rupture of iris prolapse, and the post-placed sutures were tied down. The Simcoe I&A apparatus cleaned up excess cortical material and polished the capsule. There was a small rent in the posterior capsule at about 10 o'clock, but there was no vitreous prolapse. The chamber was then filled with Healon, and a curved tying forceps placed a 95UV 22 diopter lens in the bag inferiorly and dialed horizontally with a Sinskey lens hook. Miochol was used to bring down the pupil, and the Simcoe was used to clean out excess Healon. Nine 10-0 nylon sutures were used to close the wound, and two 8-0 Vicryl sutures closed the conjunctiva. Solu-Medrol was injected sub-tenons inferiorly and Pilopine gel, Maxitrol ointment, and Telfa pad, patch, and shield were applied. The patient was sent to the recovery area. There were no complications.

SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

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