Deck 13: Eye and Auditory Systems

Question 1

Case
-T13-2A OPERATIVE REPORT, CATARACT EXTRACTION AND LENS IMPLANT
LOCATION: Outpatient, Hospital
PATIENT: Audrey Slocum
ATTENDING PHYSICIAN: Rita Wimer, MD
PREOPERATIVE DIAGNOSIS: Cataract, left eye
POSTOPERATIVE DIAGNOSIS: Cataract, left eye
PROCEDURE PERFORMED: Cataract removal by phacoemulsification with posterior chamber intraocular lens implantation (Allergan mode SI90NB, 15 diopter, serial #1895008)
ANESTHESIA: Topical
ESTIMATED BLOOD LOSS: Minimal
COMPLICATIONS: None
PROCEDURE: In the operating room, after intravenous sedation, the patient was prepped and draped in the usual sterile fashion for an intraocular procedure of the left eye. A lid speculum was placed. A Weck-cel soaked with lidocaine 4% MPF was placed at the limbus, in the area of both the planned phaco incision and the planned sideport incision. The conjunctiva was opened with the Wescott scissors, and electrocautery was used to control scleral bleeding. A 3.0 keratome was used to enter the chamber. Lidocaine 1% preservative-free was injected into the eye. A sideport incision was then made. Viscoelastic was used to exchange the aqueous. A continuous tear capsulotomy was performed. The nucleus was hydrodissected and removed with phacoemulsification using an ultrasound time of 1.9 with an actual phaco percentage of 11%. The remaining cortical material was removed with irrigation/aspiration. The capsule was polished and vacuumed as appropriate. A very small amount of lidocaine 1% preservative-free was again injected into the eye. Viscoelastic was used to deepen the chamber, and the posterior chamber intraocular lens was unfolded into the capsular bag and dialed into position. Irrigation/aspiration was used to remove the remaining viscoelastic. The wound was tested and found to be watertight. The patient left the operating room in stable condition, having tolerated the procedure well.
T13-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 1

Professional Services: 66984-LT (Cataract, Removal/Extraction, Extracapsular)
ICD-10-CM DX: H26.9 (Cataract)
Explanation: The service is an extracapsular cataract removal of the left eye reported with code 66984 and modifier -LT to indicate left.
The diagnosis is stated to be cataract of the left eye reported with H26.9 as a more specific type is not indicated in the report.

Question 2

Case
-T13-2B OPERATIVE REPORT, ADENOIDECTOMY, PE TUBES
LOCATION: Outpatient, Hospital
PATIENT: Slade Siders
ATTENDING PHYSICIAN: Jeff King, MD
PREOPERATIVE DIAGNOSES:
1. Bilateral recurrent acute otitis media.
2. Chronic otitis media.
3. Conductive hearing loss.
4. Nasal obstruction secondary to adenoid hypertrophy.
POSTOPERATIVE DIAGNOSES:
1. Bilateral recurrent acute otitis media.
2. Chronic otitis media.
3. Conductive hearing loss.
4. Nasal obstruction secondary to adenoid hypertrophy.
PROCEDURE PERFORMED:
1. Bilateral PE (pressure equalization) tube placement.
2. Primary adenoidectomy.
3. Intraoperative ABR (auditory brain-stem response) testing.
OPERATIVE NOTE: The patient is a 12-year-old who was seen in the office and diagnosed with the above condition. The decision was made in consultation with his parents to undergo the above-named procedure.
He was admitted through the same-day surgery program, where he was administered a general anesthetic by intravenous injection. He was then intubated endotracheally. A 4-mm (millimeter) speculum was inserted into the right ear, and wax was removed from the canal. An anterior/inferior incision was created, and a large amount of glue-like material was removed from the middle ear cavity. PE (pressure equalization) tube was placed through the incision, and two drops of Cortisporin were applied. The speculum was removed and inserted in the opposite ear. Again, wax was removed from the canal. An anterior/inferior incision was created, and a glue-like material was removed from the middle ear cavity. PE tube was placed through the incision, and two drops of Cortisporin were applied. The speculum was then removed. The patient was turned 90 degrees. A Jennings gag was placed in the mouth and expanded. This was secured to a Mayo stand. Two red rubber catheters were placed through the nose and brought out through the mouth. These were secured with snaps. This was done to elevate the palate. The laryngeal mirror was placed in the nasopharynx. The adenoid tissue was visualized. There was a significant amount present here. Suction cautery was then used to remove this in a systematic fashion. This produced a marked improvement in the nasal airway. We then turned the patient back 90 degrees, and the inserts were placed in each ear for limited ABR testing. This was performed under my supervision. When this was completed, the patient was allowed to recover from the general anesthetic and taken to the post anesthesia care unit in stable condition. There were no complications during this procedure.
T13-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 2

Professional Services: 42831 (Adenoids, Excision), 69436-51-50 or 69436-51 (Tympanostomy), 69436-51-50 (Tympanostomy), 92586-26 (Audiometry, Brainstem Evoked Response)
ICD-10-CM DX: J35.2 (Hypertrophy/hypertrophic, adenoids), H66.90 (Otitis media, acute and chronic), H90.2 (Deafness, conductive)
Explanation: The report indicated in the Procedure Performed section that the adenoidectomy was primary. There are codes for a primary adenoidectomy, which is the initial removal of the adenoids, and a secondary adenoidectomy, which is a subsequent removal of tissue that was not removed during the previous surgical procedure. An initial removal for a patient age 12 or over is 42831.
The tympanostomy placement of tubes is bilateral in this case (sometimes only one tube is inserted) and is reported with 69436 for one tube. The format of the reporting is dependent upon the third-party payer. Some payers would direct the provider to report the procedure code only one time with modifier -50 (bilateral procedure), other payers would direct the code to be reported twice with -51 and -50 on the second code. Note that for the professional service, the modifier -51 is used with 69436 on both appearances of the code as the adenoidectomy is the most resource intensive and would be listed first, followed by other procedures performed during the same operative session with -51 added (unless it is the hospital bill, in which case -51 is omitted).
The ABR (auditory brainstem response) is an audiometry (measurement of hearing) in which electrodes are placed on the scalp and the auditory system is stimulated. An electrical recording is made of the results from auditory nerve and brainstem. The operative report stated the test was limited and the service is reported with 92586. The professional portion of the service was provided by the physician (-26), and the technical portion of the service was provided by the facility (-TC).
The tympanostomy was performed due to acute and chronic otitis media and reported with H66.90.
The patient has both acute otitis media and chronic otitis media. The operative report refers to "glue-like" material but does not specify that this is purulent (pus) or otherwise. As a result, the unspecified code, H66.90, must be used.
The conductive hearing loss is not specified as unilateral or bilateral nor is the location (external, inner, middle, tympanic membrane, etc); therefore, the unspecified code H90.2 must be used. The operative report specifies the tubes were put in the middle ear. ("An anterior/inferior incision was created, and a large amount of glue-like material was removed from the middle ear cavity.") This would seem to support that this is a bilateral middle ear conductive hearing loss. But before it can be coded as such, the physician should be asked to clarify and document.

Question 3

Case
-AUDIT REPORT T13.2 OPERATIVE REPORT, MYRINGOTOMY WITH TYMPANOSTOMY TUBE PLACEMENT
LOCATION: Outpatient, Hospital
PATIENT: Lynn Welsh
ATTENDING PHYSICIAN: Jeff King, MD
SURGEON: Jeff King, MD
PATIENT: Lynn Welsh
ATTENDING PHYSICIAN: Jeff King, MD
PREOPERATIVE DIAGNOSIS: Chronic otitis media with effusion, bilateral Eustachian tube dysfunction
POSTOPERATIVE DIAGNOSIS: Chronic otitis media with effusion, bilateral Eustachian tube dysfunction
PROCEDURE PERFORMED: Bilateral myringotomies and tympanostomy tube placement
ANESTHESIA: General anesthetic by inhalational mask technique
PROCEDURE: Following informed consent from the parents, the child was taken to the operating room and placed supine on the operating table. The appropriate monitoring devices were placed on the patient. General anesthesia was induced. It was maintained by inhalational mask technique. The right ear was initially evaluated. Wax was removed. A radial incision was made at the 6 o'clock position on the right tympanic membrane. A large amount of thick mucoid effusion was suctioned. A tube was placed. Topical antibiotic drops were then applied. The patient then had the left ear evaluated. Wax was removed. A radial incision was made at the 6 o'clock position on the left tympanic membrane. A large amount of mucoid effusion was suctioned from behind the left tympanic membrane. A tube was then placed. Topical antibiotic drops were then applied. The patient was then allowed to recover from general anesthesia. She was transferred to the recovery room in good condition. She tolerated the procedure well.
T13.2:
SERVICE CODE(S): 69420_________________
ICD-10-CM DX CODE(S): H66.93___________
INCORRECT/MISSING CODE(S): ________________________________________

Answer 3

Incorrect/Missing code(s): 69420, modifier -50, H66.93, H69.83
Explanation: The procedure performed was a myringotomy with tympanostomy placement (69436).
The placement of PE tubes in the ears in this case is due to chronic otitis media with effusion (H65.493) and Eustachian tube dysfunction/disorder (H69.83). The modifier -50 indicates the procedure was performed bilaterally.

Question 4

Case
-T13-1A 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:
1. Cataract, OD (right eye).
2. 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.
T13-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 5

Case
-T13-1B OPERATIVE REPORT, TYMPANOSTOMY TUBES
LOCATION: Outpatient, Hospital
PATIENT: Maurice Nicole
ATTENDING PHYSICIAN: Jeff King, MD
PREOPERATIVE DIAGNOSES:
1. Bilateral chronic mucoid otitis media with effusion.
2. Bilateral eustachian tube dysfunction.
POSTOPERATIVE DIAGNOSES:
1. Bilateral chronic mucoid otitis media with effusion.
2. Bilateral eustachian tube dysfunction.
PROCEDURE PERFORMED: Bilateral pressure equalization tube placement
ANESTHESIA: General anesthetic by inhalation mask technique
PROCEDURE: Following informed consent from the patient's mother, he was taken to the operating room and placed supine on the operating table. The appropriate monitoring devices were placed on the patient, and general anesthetic was induced. He was maintained by inhalation mask technique. The right ear was evaluated under the operating microscope. Wax was removed. A radial incision was made at the 6 o'clock position on the right tympanic membrane. A thick effusion was suctioned from behind the right tympanic membrane. A tube was placed. Topical antibiotic drops were then applied.
The left ear was evaluated. Wax was removed. A radial incision was made at the 6 o'clock position. A very thick mucoid effusion was suctioned from behind the left tympanic membrane. A tube was then placed. Topical antibiotic drops were then applied.
The patient tolerated the procedure well and was transferred to the recovery room in good condition.
T13-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 6

Case
-AUDIT REPORT T13.1 OPERATIVE REPORT, MYRINGOTOMY AND ADENOIDECTOMY/TONSILLECTOMY
LOCATION: Outpatient, Hospital
PATIENT: Terri Laffe
ATTENDING PHYSICIAN: Jeff King, MD
SURGEON: Jeff King, MD
PREOPERATIVE DIAGNOSIS:
1. Chronic adenotonsillitis.
2. Adenotonsillar hypertrophy.
3. Chronic serous otitis media.
POSTOPERATIVE DIAGNOSIS:
1. Chronic adenotonsillitis.
2. Adenotonsillar hypertrophy.
3. Chronic serous otitis media.
PROCEDURE PERFORMED:
1. Bilateral myringotomies.
2. Tonsillectomy.
3. Adenoidectomy.
PROCEDURE: The patient was admitted through the same-day surgery program and taken to the OR. A general endotracheal anesthesia was administered. A 4-mm speculum was then inserted in the right ear, and wax was removed from the canal. A small incision was made, and a small amount of fluid was removed. The same was then performed on the left ear. The patient was then turned 90 degrees. A McIvor mouth gag was inserted. The patient's tonsils were touching in the midline. The left tonsil was removed by snare technique, and then bismuth packs were placed. The right tonsil was removed by snare technique, and then bismuth packs were placed. Adenoids were removed with the use of adenotome curettement and biopsy forceps. Nasopharynx was both visually examined and palpated to be sure the adenoids have been removed, and then bismuth packs were placed. Packs were serially removed, and electrocautery was used to attain hemostasis in all three areas. The nasal and oral cavities were washed well with saline. All three areas were reexamined, and when good hemostasis was present, they were painted with viscous Xylocaine. The patient was then awakened from his anesthetic and returned to the recovery room in stable condition.
T13.1:
SERVICE CODE(S): 42820, 69421_____________
ICD-10-CM DX CODE(S): J35.03, J35.3, H65.23
INCORRECT/MISSING CODE(S): ________________________________________