Rationale: ICD-10-CM lists many of the codes for eye disorders or injuries based on which eye was affected (laterality - left, right, bilateral or unspecified). A patient has heavy skin and muscle (myogenic) that is drooping down and blocking his vision due to myogenic ptosis of the upper eyelid.
Full Answer
2021 ICD-10-CM Codes S05*: Injury of eye and orbit. ICD-10-CM Codes. ›. S00-T88 Injury, poisoning and certain other consequences of external causes. ›. S00-S09 Injuries to the head. ›. Injury of eye and orbit S05.
Injury of eye and orbit S05- >. ICD-10-CM Diagnosis Code S02.3 ICD-10-CM Diagnosis Code S02.8 ICD-10-CM Diagnosis Code S00.1 ICD-10-CM Diagnosis Code S00.2 "Includes" further defines, or give examples of, the content of the code or category.
RATIONALE: In the CPT® Index, look for Ophthalmology, Diagnostic/Eye Exam/Established Patient referring you to 92012-92014. A comprehensive exam includes a biomicroscopy and tonometery. Code 92002 is reported for a new patient and 92012 for an existing patient. This service is for an existing patient, making 92012 the correct code.
ICD-10-CM Diagnosis Code S04.0. Injury of optic nerve and pathways. 2016 2017 2018 2019 2020 2021 Non-Billable/Non-Specific Code. Use Additional. code to identify any visual field defect or blindness ( H53.4-, H54.-) S04.0-) 3rd cranial [oculomotor] nerve injury (. ICD-10-CM Diagnosis Code S04.1.
Rationale: In the CPT® Index look for Otoplasty which directs you to code 69300 and is confirmed by the code description in the Auditory System numeric section. The parenthetical note beneath 69300 instructs us to report the code with modifier 50 for a bilateral procedure.
Rationale: In the CPT® Index look for Auditory Canal/External/Removal/Foreign Body which directs you to code range 69200-69205. Verify the code in the numeric section. Code 69200 is the appropriate code for the removal of a foreign body from the external auditory canal without general anesthesia. Code 69205 is with anesthesia. Under direct visualization the foreign body is removed from the external auditory canal using delicate forceps, a cerumen spoon or suction. No anesthetic or local anesthetic is used.
Rationale: This is a repair of blepharoptosis. In the CPT® Index, look for Blepharoptosis/Repair directs you to code range 67901-67909. The codes are selected based on the approach and technique. After verifying in the numeric section, code 67908 is the correct code.
PROCEDURE: The patient was prepped, and draped in the usual manner after first undergoing retrobulbar anesthetic. A lid speculum was inserted. An incision was made at approximately the 10 o'clock meridian 3 mm in length, 2 mm posterior to the limbus, and grooved forward into clear cornea with a 3.2 mm anterior chamber. An anterior vitrectomy was carried out, placing a visco-elastic substance in the anterior chamber to maintain it. A Sinskey hook was used to sweep vitreous away from the corneal wound and this was removed with the disposable vitrectomy instrument. The patient's pupil is noted to be round. There was no vitreous to the wound. The wound self-sealed without aqueous leak. Cautery was used to close the conjunctiva. Subconjunctival Decadron and Gentamicin was given. The patient tolerated the procedure well and was discharged to the recovery room in good condition. What CPT® code (s) is/are reported?
Rationale: Exophthalmos is a protruding eyeball anteriorly out of the orbit ( eye socket). When there is an increase in the volume of the tissue behind the eyes, the eyes will appear to bulge out of the face.
Rationale: In the CPT® Index look for Tympanostomy/General Anesthesia directing you to 69436 , then verify the code in the numeric section. Code 69436 is the correct code to report because a small incision is made in the tympanum, the fluid in the middle ear is suctioned, and an insertion of a small ventilating tube is placed into the opening of the tympanum under general anesthesia. Modifier RT is appended to indicate the side of the body the procedure was performed. In the ICD-10-CM Alphabetical Index look for Otitis/media/chronic/serous which states see Otitis, media, nonsuppurative, chronic, serous. Look for Otitis/media/nonsuppurative/chronic/serous directing you to H65.2. The Tabular List indicates a 5th character is needed to show laterality. 5th character 1 is for the right ear.
Rationale: In the CPT® Index look for Auditory Canal/External/Biopsy. Verify in the CPT® numeric section. Code 69105 with modifier LT is correct since the biopsy was taken from the left ear in the auditory canal.
RATIONALE: In the CPT® Index, look for Mastoidotomy. Code 69637 represents a mastoidotomy (including atticotomy and tympanic membrane repair) with ossicular chain reconstruction and partial ossicular replacement prosthesis.
RATIONALE: In the ICD-10-CM Alphabetic Index look for Neuroma/acoustic (nerve) D33.3. Although an acoustic neuroma is indexed to D33.3, the question indicates malignant which changes the way the diagnosis is reported. A note at the beginning of the Table of Neoplasms discusses classifications in the columns of the table, and advises, "the guidance in the index can be overridden if one of the descriptors is present." Because the pathologist stated this particular acoustic neuroma is malignant, the word malignant overrides the index entry. Look in the Table of Neoplasms for Neoplasm, neoplastic/acoustic nerve/Malignant Primary which directs you to C72.4-. Verify in the Tabular List and code C72.40 is reported because the laterality is not addressed. It's very important to study and understand the information provided in the guidelines and notes within the codebook. Be willing to look beyond the codes for the answers because the answers may be in the instructional notes and guidelines.
RATIONALE: Without more specific information for the type of hearing loss, a nonspecific diagnosis is reported. In the ICD-10-CM Alphabetic Index, look for Loss/hearing (see also Deafness). Look for Deafness directing you to H91.9-. In the Tabular List, select code H91.90 Unspecified hearing loss, unspecified ear. No scientific study of the hearing loss was made, making R94.120 incorrect.
RATIONALE: In the CPT® Index, look for Strabismus/Repair/Superior Oblique Muscle 67318. Code 67318 is the only code listed describing a procedure on the superior oblique muscle. In addition to 67318, report add-on codes for adjustable sutures. In the index, see Strabismus/Repair/Adjustable Sutures 67335. This patient has a history of ophthalmic surgery . The medical history of ocular surgery makes the procedure riskier and more difficult. Look in the index for Strabismus/Repair/Previous Surgery, Not Involving Extraocular Muscles 673331. Modifier 51 never is applied to add-on codes.
NAME OF PROCEDURE: Right tympanoplasty via the postauricular approach.
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.(The concha, which is the external part of the ear, is sutured in place.) Three tacking sutures were used.
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.