Hi, today we're going to talk about the Eye
and the Ocular Adnexa and the Auditory
System.The subsection here involves
procedures on the eyeball, the anterior
segment, the posterior segment, the
ocular adnexa and the conjunctiva. The
different parts of the eyes I have
here in parentheses. I got that out of the
CPT code book, looking at the Table of
Contents and seeing which parts of the
body were included on the anterior
segment, for example. So if you ever don't
know what is included in a given section,
you can go to the Table of Contents and
follow it there. This is a screenshot
taken from the CPT code book showing the
eye's anatomy. I write in pencil so that I
can erase and so it's not very dark on a
slide but you can see where I have
referred myself to page 418 in the code
book to see all of the muscles.
This particular diagram only shows the
two horizontal muscles. Each eye has six
muscles so we have to always watch our
code descriptions and be sure that they
are written to unilateral or bilateral
so that you use the appropriate
modifiers. When I refer myself to
this page, here are all the extraocular
muscles of the right eye and it's
telling me each one of the six and where
they're located on the eye.
There's also an unlisted category in the
section and many of the Lasik procedures
are categorized in this category for the
anterior segment. Rather than having a
specific CPT code, you're going to go to
that "Unlisted" category. I have here
that Lasik is the acronym (I'm not sure
I can say this correctly). I believe it's
pronounced laser in situ keratomileusis.
Fortunately we get to just say
"LASIK". As I mentioned earlier, be sure
that you read your descriptions
carefully. Most of the eye procedures are
unilateral, so if a surgeon is performing
the same procedure on both eyes, you will
need a modifier. If it's unilateral, you're
also going to use a modifier (left or
right) and if it's related to the eyelid,
remember that there are specific
modifiers located on the inside cover of
the front page of the CPT code book that
tell you which modifier you would use
for the eyelids. Another procedure is a
cataract extraction and there are many
parts listed at the beginning of this
(extraction) subsection but you do not code
separately because they are considered
part of the extraction procedure. The
two types of extractions are "extracapsular"
and "intracapsular". "Extracapsular"
includes removal of the lens material
without removing the posterior capsule
and "intracapsular" extraction is removal
of entire lens including the posterior
capsule. Often you will see a procedure
where the cataract is extracted and then
an intraocular lens prosthesis is
inserted. Codes are differentiated by
whether or not this intraocular lens
prosthesis is inserted during the same
operative episode of the cataract
extraction or in a subsequent encounter.
This is listed here in these codes on this slide.
Strabismus is a condition where one of
the eyes is either turned inward
or outward
and this is surgically corrected on the
muscles that regulate the movement of
the eyeball. This range of codes requires
documentation of the number of muscles
involved and the type (horizontal or
vertical). As I mentioned earlier,
procedure descriptions are usually
unilateral, so always watch for your
narrative and your operative report to
be sure that you're picking up on
whether or not it is one eye or more than
one eye. Here we have a list of those six
muscles that are attached to each eye. The
two horizontal named lateral rectus and
medial rectus which move the eye from
side to side and there's four vertical
muscles- inferior rectus, superior rectus,
inferior oblique and superior oblique
which move the eye up and down. Here's our
first scenario. Strabismus correction
involving the lateral rectus muscle. One
thing I did differently for this podcast
is I have inserted "medical necessity". You
always must have medical necessity any
time you have a procedure. I just haven't
made it a part of our slides to this
point but i want to start doing that. I
also want you to continue to use
your ICD-10 book because when you get
into the (coding) field, if you're going to be a
coder, you'll be using all your codebooks.
You will not be great on this (new concept),
obviously, but it just gives you an
opportunity to use the skill set that
you developed finding codes in ICD-10-CM.
Find those codes and I will have the
correct answers here for you so you can
check yourself. In this particular
surgery, the procedure is involving the
lateral rectus muscle so if you remember
from an earlier slide, the code book is going
to ask how many muscles are
involved and the type so when we go to
this screenshot
of the code book, and here's the codes
down here at the bottom where I have them in
my code family. I have it circled. Strabismus
surgery involving one horizontal
muscle, two horizontal muscles, one
vertical muscle, or 2 or more vertical muscles.
There's also good diagrams in your code
book about the strabismus
surgery, both horizontal and vertical.
Here's your correct answer. You see that the
lateral rectus is a horizontal muscle.
Here's your ICD-10 code. If we had a
true case study or were reading an
actual medical record, it would probably
have a lot more information than what
we're given in our textbook, our CPT
textbook so I only have Strabismis,
unspecified. There's many types of
strabismus when you look in your
ICD-10-CM code book but I just chose the
"unspecified" because that's all I know at
this point and this is the code that you would
use. Again, I'm just adding the medical
necessity (concept) so that you become aware you
will always need (to state) medical necessity any
time you're doing a procedure. Your job in
these exercises is just to find a CPT
code associated with this body system.
Strabismus is your main term you're going to
find in the Index, with Repair and one
horizontal muscle, the lateral rectus. As
a reminder, if you can't remember, you're going
to go back up here, find your muscles and
if you might be a good idea to write in
your code book this information. Lateral
rectus and medial rectus are your horizontal
muscles and the four vertical
muscles are the inferior rectus, superior
rectus, inferior oblique and superior
oblique. Okay, the next one is orbitotomy
of the right eye to remove a piece of
glass. Now I search for this term "orbitotomy"
or use my google search engine
where you type in orbitotomy, followed by
a colon and "Enter" to "search" (for the term) and it
will give you a definition. This tells
me it's
a surgical incision made into the
orbit of the eye to allow the removal of
a tumor or foreign body, treat a lesion or
drain an abscess. If you remember
your medical terminology, the suffix
"-otomy" is "cutting into".
(For) medical necessity, your diagnosis is a
penetrating wound of the orbit with a
foreign body, right eye and here is our
correct code group. You see that the
first group of codes is an orbitotomy
obitotomy
without a bone flap and the second group
below it is with a bone flap. There's no
mention of the bone flap (in our scenario) so we will not
be coding that. Here is our answers.
Be sure you add your modifier for the
right eye and here's the ICD-10-CM code to
demonstrate our medical necessity. You
have to be careful too when you're coding
these ICD-10 (diagnoses) because I assumed it was a
penetrating wound because they had to go
into the eye to remove a piece of
glass. Again. if you were reading an
entire medical chart, you would have a lot more
information than just this phrase. There
are external, you can have foreign bodies
in the external eye as well. Those would
be different codes. Here is an
excisional transverse blepharotomy with
one-third lid margin rotation graft.
Anytime you see if the words "excision"
and then a "graft", you are repairing
something. In this case, the blepharotomy
tells us that's an eyelid. You're
cutting into an eyelid. I give you a
little information here. If you've never
heard of this type of procedure, you can
go in, like I copied the entire phrase
there for the procedure and searched and
read a couple of websites just to get an
idea of when a student or coder might
see this particular procedure. I have
information here in my note, "usually
caused by burns or something physical,
accident or a severe chronic
inflammatory disease such as trachoma."
I looked up trachoma (because) I was
familiar with that word and it is a
contagious bacterial infection on the
eye that affects the inner surface of
the eye, the eyelid, Then when I go to
the ICD10 book, what do you know, there
is a diagnosis of trachoma. I chose
"active stage" because the fact that a
graft is being done, I'm assuming this is
something that's been ongoing and is now
being treated this way. Again, if you were
reading a medical chart in its entirety,
there would not be an assumption. You
would have the facts there for you (in the medical record) and if
not, you would have to query the doctor.
More than likely, these things would
be in there and here's your ICD-10 code
for trachoma and your CPT code for your
eyelid repair. You notice in the index
there the first entry is "excisional" and
then there's an indentation where it
says "over one-fourth of lid margin". In
our procedure description here, it
says "one-third". One-third is more than
one-fourth, therefore, you would use the
67966 code. Next procedure, a patient has
trichiasis and cryosurgery is being used
to destroy those follicles. These are
eyelashes that are chronically growing
in so that the patients have to have a
procedure so the doctor's going to go in
and just use cryo to destroy those
particular specific hair follicles that
are continuing to grow in. The
diagnosis is (trichiasis) of the right lower lid.
Here you see this is showing you an
ingrown hair or eyelash and where the
physician is going in and just removing
that one follicle, destroying it so that
hair no longer continues to grow and
irritate the eye. Also, in this particular case you
would be using a modifier to indicate
the eyelid, which side it was on. In this
case, it's the lower right and here's
your CPT code. Here's your index pathway
and here is your ICD-10 code
demonstrating medical necessity.
As a reminder, you do not have to look
these up. I'm trying to give you an
opportunity to continue to use your
skill set of finding ICD-10 codes
because oftentimes you forget. If you
don't use those skills, you forget them
so I'm going to try to just make it
available to you. It in no way
impacts your grade. I just want you to
have the opportunity to look up some
ICD-10 codes. If you're wondering why
are we not using (ICD-10)PCS, well let's think
about this. CPT is for outpatient, outpatient
procedures and outpatient procedures use
ICD-10-CM to demonstrate medical
necessity, the same as inpatient
procedures but inpatient procedures do
not use CPT Codes. Inpatient procedures use
ICD-10-PCS, These are different code sets. So here's
our next exercise where the patient has
severe diabetes with retinopathy and
macular edema. The surgeon is using laser
photocoagulation to resolve the leaking
microaneurysm so some leaking
blood in the retina. So your diagnosis
would be, and your medical necessity,
diabetes with retinopathy and macular
edema.So we look up that procedure for
the photocoagulation and here it is. It
has a specific term 67210.
Here is the CPT code for
photocoagulation of a lesion of the retina
and here's your ICD-10 code for the diabetes
with retinopathy and macular edema.
In case you're wondering "leaking micro
aneurysms" that is integral to this
condition of having retinopathy and macular
edema. You have the edema because these
things are leaking so the idea is to
coagulate or destroy those lesions that
are leaking on the retina. Now, let's look at the ear.
There are procedures in the
CPT code book for the inner, outer and
the middle ear. You can see them divided by
subsection, but remember that services
such as audiometry and vestibular
testing which are diagnostic to whether
or not someone has any hearing problems
or ear- related problems, those
diagnostic services are in the Medicine
section (of the CPT code book) which we will be doing in a few
weeks, and not found in the auditory system.
If you need to make yourself a note
about that you can because it is
something we haven't covered yet. So it
may be a little confusing. One of
the most common procedures in this
section, the auditory section, is
tympanostomy. which is the little
ventilating tube doctors put in the ears of babies
or small children with chronic ear
infections. The physician may dictate
the term "myringotomy" when he's
putting in these ventilating tubes, but
the coder is going to code that
procedure as a tympanostomy. I think I
mentioned to you in an earlier podcast that
a physician may not use the word you
need to code so you have to look at what
he or she is doing and code what they're
doing based upon what you understand for
the terminology in the CPT code book.
This is just one example. In our first
exercise, under general anesthesia a
surgeon is removing a pebble from the
external auditory canal of a
one-year-old. So our medical necessity is
the foreign body in the left ear and
here you see in our CPT code book, the
codes differentiated by "without general (anesthesia)"
and "with general (anesthesia)". It sounds a little
excessive to me to have general
anesthesia but if you think about a
one-year-old, trying to hold a
one-year-old still while you're messing
with his or her ear. It probably
wouldn't feel too good and there you
might accidentally, if the baby jumped or
did something, you might accidentally
damage the eardrum with the tools that
you're using to remove the foreign body. So
it would be much safer to put a baby to
sleep and not risk any damage to the ear.
Here is the "T" code for the foreign
body in the left ear and here's your CPT
code. This is just demonstrating medical
necessity, not part of this course, just
to reminder to you that you will always need to
demonstrate medical necessity before you
have a procedure, whether its inpatient
or outpatient. You have to demonstrate
medical necessity. The CPT code is
here with the left modifier- LT for the
"left ear". Here's the last one. Surgeon
inserts cochlear implants in both ears.
Our medical necessity is unspecified
hearing loss, bilateral. Here you have the
cochlear implant. There's just one code
69930 for cochlear implants because the
with or without a mastoidectomy. There is no
mention of a mastoidectomy
in our procedure but it doesn't matter, it's
the same code. Here's the code H91.93
for the hearing loss and don't
forget your modifier - 50 because the
surgeon is implanting in both ears.
If you have any questions about the eye
or the ear, put your question in discussion board
along with the path you have used to try
and find the code and I will answer them
there so we can all learn together. Thank
you so much and have a good day.