Chapter 15: CPT Eye and Ocular Adnexa, Auditory Systems Workbook Answers and Rationale.
Case 1
Anesthesia: Laryngeal mask anesthesia.
Preoperative Diagnosis: Retinal detachment, right eye.
Postoperative Diagnosis: Retinal detachment, right eye. |1|
Procedure: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right eye.
Procedure: After the patient had received adequate laryngeal mask anesthesia, he was prepped and draped in usual sterile fashion.
A wire lid speculum was placed in the right eye.
A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors. Each of the intramuscular quadrants was
dissected using Aebli scissors. The muscles were isolated using a Gass muscle hook with an 0 silk suture attached to it. The patient
had an inspection of the intramuscular quadrants and there was no evidence of any anomalous vortex veins or thin sclera. The
patient had an examination of the retina using an indirect ophthalmoscope and he was noted to have 3 tears in the temporal and
inferotemporal quadrant and 2 tears in the superior temporal quadrant. |2| These were treated with cryoretinopexy. |3| Most posterior
edge of each of the tears was marked with a scleral marker followed by a surgical marking pen. The patient had 5-0 nylon sutures
placed in each of the 4 intramuscular quadrants. The 2 temporal sutures were placed with the anterior bite at about the muscle
insertion, the posterior bite 9 mm posterior to this. In the nasal quadrants, the anterior bite was 3 mm posterior to the muscle
insertion and the posterior bite was 3 mm posterior to this. A 240 band was placed 360 degrees around the eye and a 277 element
from approximately the 5-1 o’clock position. The patient had another examination of the retina and was noted to have a moderate
amount of subretinal fluid, so a drainage sclerotomy site was created at approximately the 9:30 o’clock position incising the sclera
until the choroid was visible. |4| The choroid was then punctured with a #30-gauge needle. A moderate amount of subretinal fluid
was drained from the subretinal space. The eye became relatively soft and 0.35 ml of C3FS gas was injected into the vitreous cavity
3.5 mm posterior to the limbus. The superior temporal and inferior temporal and superior nasal sutures were tied down over the
scleral buckle. The 240 band was tightened up and excessive scleral buckling material was removed from the eye. |5| The inferior
nasal suture was tied down over the scleral buckle and all knots were rotated posteriorly. The eye was reexamined. The optic nerve
was noted to be nicely perfused. The tears were supported on the scleral buckle. There was a small amount of residual subretinal
fluid. The patient received posterior sub-Tenon Marcaine for postoperative pain control. The 0 silk sutures were removed from the
eye. The conjunctiva was closed with #6-0 plain gut suture. The patient received subconjunctival Ancef and dexamethasone. The
patient was patched with atropine and Maxitrol ointment.
The patient tolerated the procedure well and returned to the postoperative recovery room.
|1| The postoperative diagnosis is used for coding.
|2| Exam reveals the location of the tears.
|3| Cryoretinopexy is the use of intense cold to close the tear in the retina.
|4| A sclerotomy is performed to drain subretinal fluid.
|5| Sclera buckling is performed.
What are the CPT® and ICD-10-CM codes?
CPT® code: 67107-RT
ICD-10-CM code: H33.021
Rationale:
CPT® code: Multiple procedures are performed to repair the retinal detachment. In the CPT® Index, look for Retina/Repair/
Detachment/by Scleral Buckling. Review the code descriptions that are referred to in the index. All components of the
procedure are described with code 67107. Documentation indicates that gas was injected into the vitreous cavity. This
documentation does not support reporting code 67110. To report code 67110, the gas is injected through the sclera to flatten
the retina against the choroid, followed by a laser or cryotherapy to seal the retinal tear.
ICD-10-CM code: The indication for the surgery is retinal detachment. The physician documents retinal tears when the retina
is examined. To determine the ICD-10-CM code, look in ICD-10-CM Alphabetic Index for Detachment/retina/with retinal/
break/multiple H33.02-. In the Tabular List the 6th character 1 is reported for the right eye for a complete code, H33.021.
Case 2
Preoperative Diagnosis: Dacryostenosis, both eyes.
Postoperative Diagnosis: Dacryostenosis, both eyes.
Procedure Performed: Nasolacrimal duct probing, both eyes.
Anesthesia: General.
Condition: To recovery, satisfactory.
Counts: Needle count correct.
Estimated Blood Loss: Less than 1 mL.
Informed Consent: The procedure, risks, benefits, and alternatives were thoroughly explained to the patient’s parent who
understands and wants the procedure done.
Procedure: The patient was prepped and draped in the usual sterile manner under general anesthesia. |1| Starting on the right
eye |2| the upper punctum was dilated with double-ended punctal dilator, and starting with a 4-0 probe, increasing up to a 2-0
probe, the nasolacrimal duct was dilated until probed patent. |3| Then, using a curved 23-gauge punctal irrigator, 0.125 ml of sterile
fluorescein stained saline was easily irrigated down the nasolacrimal duct into the nostril where it was carefully collected with a
clear #8 catheter. The instruments were removed and an identical procedure was done on the opposite eye nasolacrimal duct. |4|
TobraDex eye drops were placed in each lower cul-de-sac. The eyelids were closed. The patient left the operating room for recovery
in satisfactory condition.
|1| General anesthesia is used for this procedure.
|2| This indicates the procedure is performed on the right eye.
|3| This indicates the nasolacrimal duct is probed.
|4| The same procedure is performed on the left eye.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 68811-50
ICD-10-CM code: H04.553
Rationale:
CPT® codes: In the CPT® Index, look for Nasolacrimal Duct/Exploration/with Anesthesia. When this procedure is performed
using general anesthesia, the code selection is 68811. During this encounter, the provider probes the nasolacrimal duct of the
right and left eyes. There is a parenthetical note to append modifier 50 if the procedure is performed bilaterally. Some payers
may require you to use modifier LT and RT instead of modifier 50. If that is the case, submit 68811-RT and 68811-LT. Payer
policy will dictate how the procedures are reported. For certification exams purposes, follow the coding guidelines in CPT®
and append modifier 50 to the procedure code.
ICD-10-CM Code: The patient is diagnosed with dacryostenosis. In the ICD-10-CM Alphabetic Index, look for Dacryostenosis,
which refers you to – see also Stenosis, lacrimal. There is no indication the condition is congenital. Look for Stenosis/lacrimal/
duct H04.55-. In the Tabular List, 6th character 3 is reported for both eyes, making the complete code H04.553.
Case 3
Preoperative Diagnosis: Bilateral protruding ears.
Postoperative Diagnosis: Bilateral protruding ears.
Procedure: Bilateral otoplasty.
Anesthesia: General.
Estimated Blood Loss: Minimal.
Complications: None.
Procedure is as Follows: The patient was placed supine then prepped and draped in the usual sterile fashion. Measurements
were taken from the helix to the mastoid at the superior, mid, and inferior portions and they were within 1 to 2 mm of the same
bilaterally and were approximately 17 mm superior, 24 mm middle, and 25 mm inferior. The right ear was begun first. |1| A curved
incision was made just anterior to the sulcus |2| of the posterior ear. This was done with a 15-blade scalpel. Electrocautery was
used for hemostasis and further dissection. An iris scissors was used to dissect the soft tissues off of the mastoid region and the
posterior ear. The concha was shut back and sutured in place with clear 4-0 nylon suture and in a horizontal mattress pattern. |3|
Three tacking sutures were used. This brought the ear back approximately 2 to 3 mm. However, greater correction was needed and
Mustarde’ sutures were placed. |4|
The mid and superior portions of the antihelical fold were placed. |5| These were spaced widely on either side of the helical fold. They
were then sutured in place, tacking the fold more acutely to a point that was deemed acceptable and held in that position. Next,
a margin of skin was excised along the posterior ear and closure of the wound was performed with 5-0 chromic suture. Prior to
closure, full hemostasis had been obtained with electrocautery. Both ears were done in the exact same fashion; therefore, only one
is dictated in detail. |6|
The patient was then checked very carefully for symmetry. Postoperative measurements were approximately 14 mm superior, 15
mm mid, and 16 mm lower.
|1| Procedure is performed on the right ear.
|2| An incision is made.
|3| The concha, which is the external part of the ear, is sutured in place.
|4| This is a suturing technique used to perform otoplasty.
|5| There are a total of three portions of the external ear that are repaired during this otoplasty.
|6| This indicates that a bilateral procedure is performed.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 69300-50
ICD-10-CM code: Q17.5
Rationale:
CPT® code: An otoplasty is performed, which is a surgical fixation of the external ear. The patient has protruding ears that
are being corrected. In the CPT® Index, look for Otoplasty, which refers the coder to 69300. The code description matches the
procedure performed. There is a parenthetical note that states if performed bilaterally to append modifier 50. If 69300 was
performed under Moderate (Conscious) Sedation, an additional code from code range 99151-99157, would be reported with
the appropriate documentation, but because general anesthesia is used no additional code is warranted.
ICD-10-CM code: To determine the diagnosis code, look in the ICD-10-CM Alphabetic Index for Prominence, prominent/
auricle (congenital) (ear) Q17.5. The cause of protruding ears develops at birth and the appearance of the protrusion can be
seen later in life. Verify code selection in the Tabular List.
Case 4: Operative Report
Preoperative Diagnosis: Foreign body, right external ear canal.
Anesthetic: General. Time began: 10:15 a.m. Time ended: 10:35 a.m.
Postoperative Diagnosis: Foreign body, right external ear canal. |1|
Pathology Specimen: None.
Operation: Removal of foreign body using the microscope.
Date of Procedure: 05/12/xx Time began: 10:21 a.m. Time ended: 10:22 a.m.
Description of Operation: Under general anesthesia |2| with the microscope in place, a pearly white plastic ball was seen virtually
obstructing the entire ear canal. Gently with a curette, this was teased out of the ear canal atraumatically. |3| The ear canal and
eardrum were perfectly intact.
The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.
|1| The postoperative diagnosis is used for coding.
|2| General anesthesia is used.
|3| The foreign body is removed.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 69205-RT
ICD-10-CM code: T16.1XXA
Rationale:
CPT® code: Look in the CPT® Index for Removal/Foreign Body/Auditory Canal, External/with Anesthesia, 69205. Modifier RT
is appended to report the procedure was performed on the right ear.
ICD-10-CM code: To locate the diagnosis code, look in the ICD-10-CM Alphabetic Index for Foreign body/entering through
orifice/ear (external) T16.-. In the Tabular List, a 7th character of A is reported for the initial visit. Two placeholder Xs are
reported to keep the 7th character in the seventh position. Placeholder X is used with certain codes to allow for future
expansion.
Case 5
Preoperative Diagnosis: Cataract, right eye.
Postoperative Diagnosis: Cataract, right eye. |1|
Procedure:
1. Complex phacoemulsification with manual stretch of the iris, right eye.
2. Peripheral iridectomy, right eye.
Anesthesia: Topical. |2|
Indications: The patient was seen in the Ophthalmology office with a complaint of decreased vision in the right eye and was
diagnosed with a cataract in the right eye. The patient was symptomatic and therefore, given the option of cataract surgery for
improved vision or observation. The details of the procedure were discussed at length as well as the potential risks, which include,
but are not limited to, permanent decrease of vision from infection, inflammation, bleeding, retinal detachment and need for
reoperation. The patient understood the above and desired to proceed with cataract surgery.
Description of Procedure: The patient received dilating drops and anesthesia in the preoperative area and was later brought into
the operating room. The patient was sedated by the anesthesia staff. The patient was then prepped and draped in the usual sterile
manner. The microscope was focused onto the right eye and the speculum was inserted to separate the eyelids. |3| The tip of the
2.8 mm keratome blade was used at the 6:00 o’clock position to create the paracentesis that after which Amvisc plus was injected
into the anterior chamber to create a deep anterior chamber. The same blade was used at 1:00 o’clock to create the main clear
corneal wound into the anterior chamber. |4| A two hand technique using iris expansion devices was used to expand the size of
the pupil. |5| The instruments were used at the sites directly opposite of one another to stretch the iris. They were then rotated 180
degrees to stretch the iris in that new meridian. The cystotome needle on the balanced salt solution syringe was used to initially
create the capsulorrhexis flap and the capsulorrhexis forceps were used to create the continuous capsulorrhexis tear. |6| A flat
tip hydrodissection cannula on the balanced salt solution syringe was used to hydrodissect and hydrodelineate the lens. The
phacoemulsification unit was used to remove the nucleus and irrigation and aspiration was used to remove the residual cortex.
|7| The bag was inflated with Amvisc plus and a lens of 27.5 diopter model SI40MB was injected into the bag |8| and then dialed into
place. The Amvisc plus was removed with irrigation and aspiration mode. The anterior chamber was then inflated to the appropriate
firmness using balanced salt solution. After the globe was inflated to the appropriate firmness, 0.1 cc of Vancomycin was injected
into the anterior chamber. The wounds were checked for leakage and none was found. The globe was checked for appropriate
firmness and found to be desirable. The speculum was disinserted and the patient was brought into the postoperative area where
postoperative instructions for surgical eye care were given, including the use of topical eye drops and the need for subsequent
follow up.
|1| The postoperative diagnosis is used for coding.
|2| Topical anesthesia is used.
|3| The procedure begins in the right eye.
|4| This describes the approach.
|5| Manual iris expansion.
|6| A capsulorrhexis tear is created.
|7| Phacoemulsification is used to break up the lens so it can be removed.
|8| An intraocular lens is inserted.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 66982-RT
ICD-10-CM code: H26.9
Rationale:
CPT® code: This case is coded as an extracapsular cataract removal because phacoemulsification is performed. The
physician also uses devices to expand the iris and a capsulorrhexis tear is created making this a complex procedure. In the
CPT® Index, look for Cataract/Extraction/Removal/Extracapsular. An iridectomy is included in code 66982 and would not be
billed separately. Modifier RT is appended to report the procedure was performed on the right eye. Code 66984 includes the
insertion of intraocular lens prosthesis and phacoemulsification, but not the complexity of devices or techniques to expand
the iris.
ICD-10-CM code: The patient is diagnosed with a cataract in the right eye. In the ICD-10-CM Alphabetic Index, look for
Cataract H26.9. There is no additional information provided to select a more specific diagnosis code. Verify code selection in
the Tabular List.
Case 6
IV Sedation and Local |1|
Preoperative Diagnosis: Cataract of the left eye
Postoperative Diagnosis: Cataract of the left eye |2|
Procedure Performed: Cataract extraction, foldable posterior chamber intraocular lens of the left eye |3|
Procedure: The patient was brought to the operating room and placed supine on the operating table. An intravenous line was
started in the patient’s left arm. After appropriate sedation, a left O’Brien and left retrobulbar block were administered, |4| which
consisted of a 50/60 mixture of 0.75% Bupivacaine and 2% lidocaine. The Honan balloon was then placed over the operative eye.
While the surgeon scrubbed for 5 minutes the patient was prepped and draped in the usual sterile fashion including instillation
of 5% Betadine solution to the left cornea and cul-de-sac, |5| which was irrigated with balanced salt solution and the use an eyelid
drape. A limbal incision |6| was performed with the super sharp blade. Provisc was injected into the anterior chamber.
A capsulotomy was performed with a cystitome and Utrata forceps |7| such that it was 6 mm and oval in shape. Hydrodissection was
performed with balanced salt solution. The nucleus was removed using the phacoemulsification |8| mode of the Alcon 20,000 Legacy
Series System by divide and conquer technique under Viscoat control. The cortex was removed using the irrigation aspiration mode.
The anterior chamber was then filled with Proviso and the AcrySof foldable posterior chamber intraocular lens was then inserted |9|
into the capsular bag and rotated into position such that the optic was well centered. The Proviso was removed using the irrigation
and aspiration mode. Miochol was injected to constrict the pupil. The wound was checked and deemed to be watertight. A collagen
shield soaked in Ciloxan and Pred Forte was applied. The standard postoperative patch and shield were placed and the patient was
transferred to the Recovery Room in stable condition.
|1| IV Sedation and local anesthesia is used.
|2| The postoperative diagnosis is used for coding.
|3| Indicates the type of intraocular lens (IOL).
|4| The surgeon performs a block and sedation which is included in the surgical package.
|5| The left eye is prepped for the surgery.
|6| An incision is made.
|7| The physician performs a capsulotomy.
|8| Phacoemulsification is performed.
|9| The intraocular lens is inserted in the capsular bag.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 66984-LT
ICD-10-CM code: H26.9
Rationale:
CPT® code: This is an extracapsular cataract removal. Phacoemulsification is performed to remove the cataract. The IOL
is inserted into the capsular bag. In the CPT® Index, look for Cataract/Extraction/Removal/Extracapsular. The procedures
performed are reported with 66984 which includes insertion of intraocular lens prosthesis. Modifier LT is appended to report
the procedure is performed on the left eye.
ICD-10-CM code: The indication of the surgery is cataract left eye. In the ICD-10-CM Alphabetic Index, look for Cataract H26.9.
There is no additional information provided to select a more specific diagnosis code. Verify code selection in the Tabular List.
Case 7
Preoperative Diagnosis: Tympanic membrane perforation, conductive hearing loss in the right ear.
Postoperative Diagnosis: Tympanic membrane perforation, conductive hearing loss in the right ear. |1|
Name of Procedure: Right tympanoplasty via the postauricular approach.
Anesthesia: General.
Estimated Blood Loss: Less than 20 ml.
Complications: None.
Specimens: None.
Indications: This is a 9-year-old white female with the above diagnoses and now presents for surgical intervention.
Intraoperative Findings: Intraoperative findings revealed tympanosclerosis posteriorly with a central eardrum perforation |2| of
approximately 30% of the surface of the eardrum. There was no cholesteatoma. The ossicular chain is intact.
Description of Operative Procedure: Under satisfactory general anesthesia the patient was given preoperative intravenous
antibiotic. The right ear was prepared and draped in the usual sterile fashion. A postauricular incision was made and the temporalis
fascia graft was harvested. |3| The posterior ear canal skin was elevated and tympanomeatal flap was developed. The Rosen needle
was used to freshen the edge of the perforation. Gelfoam was placed in the middle ear space. The graft was cut into the appropriate
size and laid medial to the remnant of the tympanic membrane anteriorly, posteriorly, inferiorly and superiorly. |4| Antibiotic
ointment and Gelfoam were placed in the ear canal. Closure of the wound was done in layers with 4-0 Vicryl for the subcutaneous
tissue and 4-0 Prolene for skin. Pressure dressing was placed around the right ear. The patient tolerated the procedure well.
|1| Code the postoperative diagnosis. Two codes are required to fully describe the patient’s conditions.
|2| The findings include additional diagnosis information.
|3| This is the approach. Postauricular incision is made behind the auricle of the ear. A graft is harvested from the temporalis fascia
to repair the perforated tympanic membrane.
|4| The graft is cut to size and placed.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 69620-RT
ICD-10-CM code: H72.01, H90.11, H74.01
Rationale:
CPT® code: In this case, the patient has a perforated tympanic membrane which requires repair. The physician uses a graft
which is obtained from the temporalis fascia. The surgery is performed on the tympanic membrane only. The physician
does not perform a procedure on the middle ear or a mastoidectomy. In the CPT® Index, look for Tympanoplasty. The code
references under Tympanoplasty include other surgical procedures. There is an instruction to see Myringoplasty. Myring/o
means tympanic membrane and plasty means surgical fixation. Myringoplasty refers to 69620. The description includes
“confined to drum head and donor area,” which describes the procedure. Code 69610 is not correct because a patch (which
is made of paper) was not placed, a graft was placed. All other tympanoplasty codes include additional surgical procedures
which is not appropriate in this case. Modifier RT is appended to identify the procedure was performed on the right ear.
ICD-10-CM code: The indication for the surgery is tympanic membrane perforation and conductive hearing loss.
In the Intraoperative Findings section, the physician documents the perforation is central and the patient also has
tympanosclerosis. In the ICD-10-CM Alphabetic Index, look for Perforation, perforated/tympanum, tympanic/central
referring you to H72.0-. In the Tabular List, a 5th character of 1 is reported for the right ear.
For the next diagnosis code, look for Loss (of)/hearing/conductive/unilateral/unrestricted hearing on the contralateral side
H90.1-. There is no mention of restricted hearing on the contralateral side. In the Tabular List, a 5th character of 1 is reported
for the right ear. A perforated tympanic membrane can heal on its own. Not all tympanic membrane perforations need to be
repaired, so the hearing loss shows why the surgery is being performed.
For the last diagnosis, look in the Alphabetic Index for Tympanosclerosis and you are directed to see subcategory H74.0. In
the Tabular List, a 5th character of 1 is reported for the right ear.
Case 8
Preoperative Diagnosis: Right otosclerosis.
Postoperative Diagnosis: Right otosclerosis.
Type of Procedure: Right stapedectomy.
Anesthesia: General endotracheal.
Findings: There was otosclerosis on the anterior footplate of the stapes |1| with preoperative conductive hearing loss in the right ear.
Description of Procedure: The patient was taken to the operating room and placed supine on the operating table. Following
induction of general endotracheal anesthesia, the head was turned to the left and the right ear was prepped and draped in the usual
fashion. Then 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the skin along the posterior ear canal wall and the skin
over the tragus.
After a short waiting time, an incision was made over the tragus and a piece of posterior tragal perichondrium was harvested
for a graft and set aside to dry. |2| A speculum was then placed in the canal. The canal was quite large. An incision was made
along the posterior canal wall, and a tympanomeatal flap was elevated and laid forward to include the fibrous annulus without
perforation. The middle ear was inspected. The ossicular chain was palpated and otosclerosis appeared to be fixing the stapes.
The chorda tympani nerve was very carefully preserved and not manipulated and was kept moist throughout the procedure. No
curetting of bone was necessary in order to access the footplate. A control hole was made in the footplate with a straight pick. The
incudostapedial joint was separated with an IS joint knife. The stapedius tendon was severed, and the superstructure of the stapes
was fractured over the promontory and removed. |3| The footplate was then picked out with a 45-degree pick, completely removing
all fragments. Great care was taken not to suction in the vestibule. The distance between the incus and the oval window was then
measured. The tragal perichondrial graft was then taken and laid over the oval window with complete coverage. |4| A 3.75 Shea
platinum Teflon cup piston |5| was then chosen. The platinum wires were opened and the shaft was placed down against the graft
and into the oval window niche. The cup was placed under the long process of the incus by gently lifting the incus, and the platinum
wires were snugly crimped around the long process of the incus. An excellent round window reflex was achieved upon palpation of
the ossicular chain at this point. |6|
Small, dry, pressed Gelfoam pledgets were then placed around the shaft of the prosthesis and over the graft. The tympanomeatal
flap was replaced. The lateral surface of the drum was covered with Gelfoam, and the canal was filled with antibiotic ointment. The
incision over the tragus was closed with running, interlocking 5-0 plain, fast-absorbing gut. A cotton ball was placed in the canal,
and the patient was awakened, extubated, and returned to recovery in satisfactory condition. He will be discharged when fully
awake and will return to my office in two weeks. He will avoid strenuous activity, keep the ear dry, keep a clean cotton ball in the
ear, apply antibiotic ointment to the tragal incision, avoid driving while dizzy, and he was given prescriptions for Lorcet Plus, Keflex,
and Xanax.
|1| Location of otosclerosis.
|2| A graft of ear cartilage is obtained for the procedure.
|3| The stapes is removed.
|4| The graft is placed.
|5| A prosthesis is used.
|6| Ossicular continuity is achieved.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 69660-RT, 21235-51
ICD-10-CM codes: H80.81
Rationale:
CPT® codes: In this case, the stapes is removed and replaced with a prosthesis. A cartilage graft is also placed. In the CPT®
Index, look for Stapedectomy/without Foreign Material. The footplate was picked out, but drill out was not necessary.
Sometimes, the footplate bone is too thick for a laser or pick to be effective. When the footplate bone is too thick, a drill
is required (footplate drill out). There is no mention of foreign material. Code 69660 is the correct code. Modifier RT is
appended to the procedure code to report they were performed on the right ear. To report the harvesting of the cartilage
graft, look in the CPT® Index for Harvesting/Cartilage Graft/Ear 21235. Modifier 51 is appended to the lesser value RVU
code when multiple procedures are performed. The CMS bilateral indicator for 21235 is zero so modifiers RT and LT are not
appended; however, some carriers may allow modifiers RT and LT.
ICD-10-CM codes: The indication for the surgery is otosclerosis. In the ICD-10-CM Alphabetic Index, look for Otosclerosis. The
documentation identifies otosclerosis located on the anterior footplate of the stapes, which is not listed as an option under
otosclerosis, so the specified type (specified NEC) is reported with H80.8-. In the Tabular List, a 5th character of 1 is reported
for the right ear. Conductive hearing loss is a sign/symptom of otosclerosis and is not reported. Verify code selection in the
Tabular List.
Case 9
Preoperative Diagnosis: Adenoidal hypertrophy and serous otitis media with effusion.
Postoperative Diagnosis: Adenoidal hypertrophy and serous otitis media with effusion. |1|
Name of Procedure: Bilateral ventilation tube placement, Donaldson-Activent type, Adenoidectomy.
Anesthesia: General |2|
Estimated Blood Loss: Less than 5 mL.
Findings: The patient is an 18 month-old |3| white male with a history of the above noted diagnosis. Operative findings included
bilateral thickened drums. He had a right and left serous effusion. The left was aerated for the most part. He had an intact palate and
a 3-4 + adenoid pad.
Technique: Patient was brought into the operative suite and comfortably positioned on the table. General mask anesthesia was
induced. Appropriate drapes were placed. Attention was turned to the right ear. |4| The external canal was cleaned of cerumen and
irrigated with alcohol. A radial incision was made in the right tympanic membrane. |5| Middle ear was evacuated of effusion and
Donaldson-Activent tube was followed by Ciprodex otic |6| drops. The same procedure was performed on the contralateral side. |7|
The bed was turned 30° m clockwise fashion. The Crowe-Davis mouth gag was inserted and suspended. The palate was palpated
and felt to be intact. The soft palate was elevated and under direct nasopharyngoscopy. The adenoid was removed with powered
adenoidectomy blade taking care to avoid injury to the Eustachian tube orifice. |8| The base was cauterized with Bovie suction
cautery and a pack was placed. After several minutes, the packs were removed. The nasopharynx and oral cavity was irrigated and
suctioned free of debris. The stomach was evacuated with orogastric tube. Re-evaluation showed no further active bleeding. Further
drapes and instruments were removed. The patient was returned to the care of Anesthesia, allowed to awaken, extubated and
transported in stable condition to the recovery room having tolerated the procedure well.
|1| Two diagnoses to report.
|2| General anesthesia is used.
|3| Age of the patient.
|4| Indication of which ear the tube will be placed.
|5| Tympanostomy.
|6| Placement of the ventilating tube.
|7| Placement of tube performed on the left side.
|8| Adenoidectomy.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 42830, 69436-51-50
ICD-10-CM codes: J35.2, H65.93
Rationale:
CPT® codes: Two procedures were performed for this case. The first procedure reported is for the removal of the adenoids.
In the CPT® Index, look for Adenoids/Excision, referring you to codes 42830-42836. Code 42830 is the correct code to report
due to the age of the patient. A secondary adenoidectomy was not performed because documentation does not indicate that
adenoid tissue had grown back since an initial adenoidectomy.
The second procedure reported is the insertion of the ventilating tubes. An incision is made in the tympanum to insert the
tubes. In the CPT® Index, look for Tympanostomy/General Anesthesia, 69436. The procedure is performed on both the left
and right ear which requires appending modifier 50. Some payers may prefer modifier LT and RT instead of modifier 50.
In that case, the codes are 69436-RT and 69436-LT. For exam purposes, follow CPT® guidelines and append modifier 50.
Modifier 51 is appended to indicate more than one procedure was performed.
ICD-10-CM codes: Two diagnosis codes are reported which identify the medical necessity for the adenoidectomy and the
tympanostomy. In the ICD-10-CM Alphabetic Index, look for Hypertrophy, hypertrophic/adenoids (infective) referring you to
J35.2. Verify code selection in the Tabular List.
The patient also had serous otitis media. The findings of the operative note indicate the serous otitis media has effusion. This
means the patient has fluid in the middle ear that cannot drain. This is supported in the documentation in which the note
states, “Middle ear was evacuated of effusion.”
In the Alphabetic Index, look for Otitis/with effusion which instructs you to see also Otitis, media, nonsuppurative; Otitis/
media/nonsuppurative referring you to H65.9-. Turn to the Tabular List to complete the code. The complete code is H65.93 to
indicate the right and left ear had this condition. Note, serous otitis media is listed as a condition in the inclusion terms for
this code.
Case 10
Preoperative Diagnosis: Left lower eyelid basal cell carcinoma
Postoperative Diagnosis: Left lower eyelid basal cell carcinoma |1|
Operation: Excision of left lower eyelid basal cell carcinoma with flaps and full thickness skin graft and tarsorrhaphy. |2|
Indication for Surgery: The patient is a very pleasant female who complains of a one-year history of a left lower eyelid lesion. This
was recently biopsied and found to be basal cell carcinoma. She was advised that she would benefit from a complete excision of
the left lower eyelid lesion. She is aware of the risks of residual tumor, infection, bleeding, scarring and possible need for further
surgery. All questions have been answered prior to the day of surgery. She consents to the surgery.
Operative Procedure: The patient was placed supine on the operating table and an intravenous line was established by hospital
staff prior to sedation and analgesia. Throughout the entire case, the patient received monitored anesthesia care. |3| The patient’s
entire face was prepped and draped in the usual sterile fashion with a Betadine solution and topical tetracaine, and corneal
protective shields were placed over both corneas. A surgical marking pen was used to mark the tumor. Markings that were 3 mm
were obtained around the tumor. |4| The tumor was noted to encompass approximately 1/3 of the left lower eyelid. |5| A wedge
resection was performed and this was marked and 2% Xylocaine with 1:100,000 epinephrine, 0.5% Marcaine with 1:100,000
epinephrine was infiltrated around the lesion. This was excised with a #15 blade. This was sent for intraoperative fresh frozen
sections. Intraoperative fresh frozen sections revealed persistent basal cell carcinoma at the medial margin. Another 2 mm of
margin |6| was discarded and a revised left lower eyelid medial margin was sent for permanent sections. The area could not be
closed primarily, thus a tarsoconjunctival advancement flap was advanced from the left upper eyelid to fill the defect. |7| This was
sutured in place with multiple 5-0 Vicryl sutures. The anterior lamella defect of skin was closed by harvesting a full-thickness skin
graft from the left upper eyelid and placing it in the left lower eyelid defect. |8| This was sutured in place with multiple interrupted
5-0 chromic gut sutures. The eyelids were sutured shut both on the medial aspect of the Hughes flap as well as the lateral aspect
of the Hughes flap with a 4-0 silk suture. |9| A pressure dressing and TobraDex ointment were applied. The patient tolerated the
procedure well and was transported back to the recovery area in excellent condition.
|1| The postoperative diagnosis is used for coding.
|2| Listed procedure.
|3| MAC anesthesia used.
|4| A margin of 3 mm is excised in addition to the lesion.
|5| The size of the lesion is 1/3 of the left lower eyelid.
|6| An additional 2 mm is excised.
|7| A flap is used to close the defect.
|8| A FTSK from the upper eyelid is used to repair the defect of the lower eyelid.
|9| A tarsorrhaphy is performed.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 15260-E2, 67966-51-E2, 67971-51-E2, 67875-51-E1-E2
ICD-10-CM code: C44.1192
Rationale:
CPT® codes: In this case, an excision of a basal cell carcinoma is performed. More than 1/3 of the lower eyelid is excised. A
full thickness graft as well as a flap (adjacent tissue transfer) is required for the closures. A full-thickness skin graft from the
left upper eyelid which was placed on the left lower eyelid defect. Skin grafts are always reported according to the recipient
site. Look in the CPT® Index for Skin Graft and Flap/Free Skin Graft/Full Thickness referring you to 15200-15261. The size is
not reported, so 15260 is assigned with HCPCS Level II modifier E2 appended to identify the lower left eye lid.
In the CPT® Index, look for Excision/Lesion/Eyelid. Refer to the codes referenced in the index. Under code 67840, there
is a parenthetical note which states, “For excision and repair of eyelid by reconstructive surgery, see 67961, 67966.” Code
67961 is for an excision and repair of the eyelid including preparation for skin graft or flap with adjacent tissue transfer or
rearrangement involving up to one-fourth of the lid margin. Code 67966 reports the excision and reconstruction with a flap
or an excision over one-fourth of the lid margin, which is one of the correct codes for this case. This can also be found by
looking in the CPT® Index for Repair/Eyelid/Excisional.
For the reconstructive procedure, in the CPT® Index look for Reconstruction/Eyelid/Tarsoconjunctival Flap Transfer.. Code
67971 indicates it is for a full thickness reconstruction of the eyelid with a flap from the opposing eyelid of up to two-thirds
of the eyelid.
A tarsorrhaphy (eyelids sewn shut) is performed. Look in the CPT® Index for Tarsorrhaphy referring you to 67875. Review the
code description for accuracy. When multiple procedures are performed, they are sequenced in order from the most labor
intensive (highest RVUs) to the lowest. In this case, the proper sequence is 15260, 67966, 67971, 67875. The procedure codes
15260, 67966, and 67971 are performed on the left lower eyelid, which is reported with HCPCS Level II modifier E2. Code
67875 is reported with HCPCS Level II modifiers E1 and E2 because both eyelids were closed shut. When multiple procedures
are performed, modifier 51 is appended to the procedure codes that are listed after the first listed CPT® code.
ICD-10-CM code: To determine the ICD-10-CM code, look in the ICD-10-CM Alphabetic Index for Carcinoma/basal cell.
There is guidance to – see also Neoplasm, skin, malignant. In the Table of Neoplasms, look for Neoplasm, neoplastic/skin
NOS/eyelid/basal cell carcinoma and report the code from the Malignant Primary column C44.11-. In the Tabular List, a 6th
character 9 and 7th character 2 is reported for the lower left eyelid.