Eye and Ocular Adnexa, Auditory Systems

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Objectives Understand the components of the eye and of the ear Define key terms Understand the most common pathologies affecting these sense organs Understand eye surgeries and ear surgeries and how they relate to pathologies Recognize common eponyms and acronyms for these specialties Identify when other sections of CPT® or ICD-9-CM should be accessed Know when HCPCS Level II codes or modifiers are appropriate

Anatomy: Eye and Ocular Adnexa Eyeball Optic nerve Ophthalmology/ ophthalmologist Optometry/optometrist Ophthalmoscope The eye is the organ of vision and consists of the eyeball and optic nerve. Study of the eye is called ophthalmology (ophthalmologist). Optometry (optometrist) is the profession concerned with examination of the eyes and related structures to determine the presence of vision problems and eye disorders; and prescription and adaptation of lenses or other optical aids for visual efficiency. The handheld instrument used to look in the eye is an ophthalmoscope.

Anatomy: Eye and Ocular Adnexa Eyeball – an inch (25mm) in diameter Sclera – white of the eye Cornea – transparent Pupil and Iris Choroid – vascular layer Retina – pigmented nerve layer Optic nerve and Optic disc The eyeball is a spheroidal body located anteriorly in the orbit of the skull. It is about an inch (25 mm) in diameter and consists of anterior and posterior portions. It is suspended by six extrinsic muscles that control its movement. The outer layer of the posterior portion is tough connective tissue, the sclera (or “white of the eye); it is continuous anteriorly with the cornea. It is the white portion of the eye and is important in maintaining a stable pressure in the eye. The cornea is transparent and highly sensitive to touch; covering the portion of the eye seen from the anterior side as the pupil and iris. The middle or vascular layer is the choroid, a very thin layer between the sclera and retina. The internal layer is the retina; this pigmented nerve layer lines the back of the eye sensing light and color, directly in contact with and sending messages along the optic nerve to the brain. The optic disc is an elevated visible portion of the optic nerve inside the eye. Images transmitted are inverted (upside down); the brain inverts these images back.

Anatomy: Eye and Ocular Adnexa Iris – regulates light entering Pupil Vitreous humor – fills posterior segment Ciliary body – suspensory ligaments of lens Lens – changes shape Anterior chamber The iris is the colored part of the eye; doughnut-shaped and the space between its free edges is the pupil. The iris has two sets of smooth muscles: a radially arranged set is responsible for enlargement of the pupil and a circularly arranged set decrease pupil size when contracted. The iris regulates light allowed in the eye working like the lens of a camera. The pupil is an opening surrounded by the iris; it adjusts according to the iris. When you have an eye exam, the doctor (ophthalmologist or optometrist) places drops containing medication on the eye relaxing the iris, making the pupil large to be able to see inside the eye. The posterior four-fifths of the eyeball is occupied by a transparent jelly-like material, the vitreous body. The vitreous membrane forms the suspensory ligament of the lens. Vitreous humor is a clear Jell-O-like substance filling the posterior segment of the eye. The ciliary body is directly continuous anteriorly with the choroid; its processes extend to the iris. They are important suspensory ligaments of the lens. The lens is not hard; it is able to change shape to accommodate focusing. The anterior chamber is the area behind the cornea, anterior to the lens. It is filled with aqueous humor, a clear liquid similar to salt water.

Anatomy: Eye and Ocular Adnexa Conjunctiva -pink eye -cul-de-sac Muscles -external The conjunctiva is a thin mucous membrane lining the inner surface of the eyelid. It folds back to cover a portion of the sclera and the anterior surface of the eyeball. The conjunctiva does not cover the cornea; it secretes a substance moisturizing the eye. “Bloodshot eyes” and “pink eye” occur with dilation of the vessels in the conjunctiva. The conjunctiva does not go all the way around the eye, if folds forming a cul-de-sac and doubles back inside the eyelids. When something gets in your eye or you lose a contact, it cannot go back behind the eye or further, the farthest it can go is to this cul-de-sac.   There are two groups of muscles associated with the eye, extrinsic and extrinsic. They work together, never one alone. Extrinsic eye muscles move the eyeball in its bony orbit; intrinsic eye muscles move structures within the eyeball. The external muscles consist of three sets: two side muscles, two top and bottom muscles and oblique. The lateral rectus muscle allows the eye to turn out and horizontally, temporally (towards the temple) and the medial rectal muscle medially (towards the bridge of the nose. If you turn your eye up and out, that is the superior rectus muscle; the inferior rectus muscle allows you to turn your eye down and out. The oblique muscles work a little differently allowing the eye to turn up an in for the inferior, or down and in for the superior oblique muscles. These six muscles together coordinate eye movements.

Anatomy: Eye and Ocular Adnexa Lacrimal gland Glaucoma -intraocular pressure Refraction 20/20 The lacrimal gland is located under the upper eyelid and below the eyebrow bilaterally, in the outer most corner of the eye. Fluid secreted serves to clean the eye and moisturize the cornea and conjunctiva. Lacrimation, is secretion of tears; when this term is used, it usually means in excess. When tears run down the face, they also drain out the nose – thus the need for a Kleenex when crying. Lacrimation can be excessive or too little; lacrimal plugs can be placed to block tears; artificial tears may be used when natural tears are lacking. Moisture and fluid is important to eye health. Blinking evenly spreads fluid over the eye. Glaucoma is an eye disease characterized by increased intraocular (inside the eye) pressure resulting in atrophy of the optic nerve and can result in blindness. Dehydration or dryness of eyes can result in difficulty with visual acuity and damage the eye. Pressure problems in the eye can affect oxygen delivery to the eye causing problems. Reduction of fluid in the eye affects shape and will affect vision. Refraction is the deflection of light when it passes from one medium into another. In order for this to work properly in the eye, the cornea, aqueous, lens and vitreous, that light passes through, must be clear. In the doctor’s office, refraction is use of lenses to improve vision. LASIK is surgical reshaping of the cornea to change refraction, improve vision and eliminate the need for glasses. Wearing contacts or glasses alters refraction to improve vision.   If one has 20/20 vision (considered normal), what does it mean? Eye exams are done with eye charts; a person is placed at a distance of 20 feet away from the chart, covers one and reads the chart. 20/20 vision means a person is able to see at 20 feet what a person with normal vision can see. A score of 20/40 indicates the patient can see at 20 feet what a person with normal vision can see at 40 feet. A score of 20/200 is considered legally blind. Eyes are tested separately and may have different “scores.”

Anatomy: Ear and Auditory System Otolaryngology Otolaryngologists – ENTs Otoscope External ear -tragus -auricle or pinna The ears are sensory organs comprising the auditory system. Otolaryngology specializes in diseases of the ear and larynx. Specialists are often referred to as ENTs for ear, nose and throat or otolaryngologists. Besides collection of sound and hearing, the vestibular system is important for maintenance of body balance and equilibrium. Examination of the ear is with an otoscope, similar to an ophthalmoscope mentioned previously.   The ear has three regions, external ear, middle ear and inner ear. All three regions are involved in hearing, only the inner ear is concerned with balance. You can see most of the external ear (external acoustic meatus, auricle or pinna); it serves to protect the eardrum and middle ear. It is also a sound collecting system funneling sound waves to travel through the ear canal to the tympanic membrane (or eardrum). It is composed of cartilage and loose fitting skin. The tragus is a small projection just in front of the ear canal. The lobule of the ear hangs inferiorly, piercing this structure is popular. The auricle opens into the external auditory canal providing a passageway for sound waves to enter the ear. The external auditory canal courses through the temporal bone of the skull approximately one inch in length and a half inch in diameter. This canal extends to the tympanic membrane or eardrum which separates the external ear from the middle ear. Tiny hairs and modified sweat glands line the canal; the glands secrete cerumen, or earwax preventing dust and other foreign objects from entering the ear. Too much earwax can impede sound transmission and hearing.

Anatomy: Ear and Auditory System Middle ear -Tympanic membrane -Ossicles – malleus, incus, stapes -Eustachian tube Oval window The middle ear begins at the tympanic membrane. It is an air filled chamber in the temporal bone. Besides the tympanic membrane, the middle ear contains three tiny bones and the eustachian tube. The tympanic membrane is made of connective tissue with rich blood vessels and nerves. It is connected to the throat and nasopharynx via the eustachian tube. Connection of the ear and throat make the ears susceptible to infections like otitis media due to bacteria traveling up the Eustachian tube to the ear. The tympanic membrane vibrates in response to sound waves converted into mechanical vibrations. Vibrations are passed through the middle to the inner ear by the three tiny middle ear bones. Middle ear bones, or ossicles, are the smallest bones in the body and are called: malleus (hammer); incus (anvil); and stapes (stirrup) named for their shape. Vibration from the tympanic membrane is transferred to the ossicles and then to the oval window, a membrane separating the middle ear from the inner ear. The auditory or eustachian tube functions to equalize the pressure on both sides of the tympanic membrane, this allows air to pass from the pharynx into the middle ear. This tube is normally collapsed, with swallowing or chewing the tube opens allowing air to move as needed.

Anatomy: Ear and Auditory System Inner ear Labyrinth Membranous labyrinth – hair cells Vibrations into nerve impulse Cochlea, Vestibule, Semicircular canal Balance – utricle, saccule Oval window, round window The inner ear is an intricate maze of fluid-filled tubes running through the temporal bone of the skull. This bony labyrinth is filled with fluid called perilymph. Inside this bony labyrinth is a second set of tubes called the membranous labyrinth filled with endolymph. This membranous labyrinth contains the actual hearing cells, or hair cells of the Organ of Corti. Movement of these hair cells converts the vibrations into a nerve impulse. The bony labyrinth has three parts; the front portion is the snail-shaped cochlea, the rear portion the semicircular canal; interconnecting the cochlea and the semicircular canal is the vestibule. The vestibule contains sense organs responsible for balance called the utricle and the saccule. The inner ear has two membrane covered outlets into the air filled middle ear, the oval window and the round window. The stapes in the middle ear vibrates on the oval window affecting fluid in the inner ear transmitting that vibration. The round window serves as the pressure valve bulging outward as fluid pressure rises in the inner ear. Nerve impulses from the inner ear travel along the cochlear nerve (8th cranial nerve) for hearing and to the vestibular nerve (8th cranial nerve) for equilibrium. The semicircular canals and vestibule function to sense movement as an acceleration or deceleration with position changes.

ICD-9-CM Alphabetic index ; Tabular List Disorders of the Eye and Adnexa (360-379) Diseases of the Ear and Mastoid Process (380-389) Table of Neoplasms ICD-9-CM There are no specific guidelines related to eye and ear in ICD-9-CM. Diagnostic codes for these organs are found in multiple sections of ICD-9-CM. Hopefully the preceding anatomy and physiology discussion helps you to locate correct codes. Remember, start in the Alphabetic index even though there are specific sections in the Tabular List on the eye, Disorders of the Eye and Adnexa (360-379); and ear, Diseases of the Ear and Mastoid Process (380-389). Disorders of the Eye and Adnexa is organized by anatomic site. General diagnosis categories for the eye include: infection or inflammation; neoplastic disease; injury; glaucoma; cataracts; retinopathy; retinal detachment and strabismus. Some eye infections are found in the Infectious and Parasitic Diseases chapter. If the infectious agent is known, it is important to report it as well, and example is MRSA (041.12). Neoplasms of the eye and ear are found in the Table of Neoplasms, but remember to start in the Alphabetic index and be specific.

Eye and Ocular Adnexa Disorders of the globe (360) Retinal detachments and defects (361) Other retinal disorders (362) Diabetic retinopathy (362.0x) Disorders of the globe (360), describes several disorders of structures of the eyeball. Retinal detachments and defects (361) report conditions most have heard of. A detached retina most often occurs as a result of trauma such as a blow to the eye. It can occur days and even weeks after the injury with seepage of fluid between layers in the retina. Patients with retinal detachment may complain of flashes of light or specks floating in front of their eye. Other retinal disorders (362), contains diagnosis codes for Diabetic retinopathy (362.0x). A serious complication for some patients with diabetes relates to their eyes and vision. Retinopathy is a non-inflammatory degenerative disease of the retina occurring in diabetics due to circulatory problems; it can be found in 90 % of diabetics in varying degrees after 20 years of clinical diabetes. It is a progressive illness beginning with hemorrhages or aneurysms in the vessels in the retina causing damage to the retina. With disease progression, scar tissue forms resulting in more serious vision problems. Other medical conditions cause retinopathy like atherosclerosis. Another medical condition seriously impacting eyes is hypertension or high blood pressure. There is a guideline listed here related to hypertensive retinopathy, two codes are necessary to identify the condition. First report the code from subcategory (362.11) Hypertensive retinopathy: then the appropriate code from categories (401-405) to report the type of hypertension.

Eye and Ocular Adnexa Glaucoma (365.xx) -intraocular pressure -congenital (743.2x) -angle – reflection of iris joins cornea Cataract (366.xx) -congenital (743.3x) Glaucoma (365.xx) results when flow of aqueous humor is not balanced. Outflow of this eye liquid through the scleral venous sinus into the blood circulation must occur at the same rate at which the aqueous is produced. When outflow decreases due to blockage, pressure builds up in the anterior and posterior chambers of the eye and is called glaucoma. This very serious condition can result in blindness due to atrophy of the optic nerve. Congenital (or present at birth) glaucoma is listed in (743.2). Glaucoma is classified based on the type of angle closure; the “angle” refers to the reflection of the iris where it joins the trabecular network of the cornea. ICD-9-CM contains good diagrams illustrating this.   Cataract (366.xx) is listed next. A cataract is complete or partial opacity of the lens of the eye. More simply, the lens has flaws or is “cloudy.” Aging can result in loss of transparency of the lens. Surgery for this condition includes removal of the “old” lens with placement of an artificial lens. The lens of the eye has several layers; specific ICD-9-CM codes are reported to indicate the specific layer. Congenital cataracts are reported with (743.3x).

Eye and Ocular Adnexa Disorders of refraction and accommodation (367) -Myopia (367.1) -Astigmatism (367.2x) Visual disturbances (368) -Diplopia (368.2) “double vision” Disorders of refraction and accommodation (367) follow. Recall, refraction is the deflection of light when it passes from one medium into another; accommodation is change in the shape of the ocular lens for various distances. A handy medical dictionary helps here with Myopia (367.1), Astigmatism (367.2x) and more. This is also true with Visual disturbances (368). An example is Diplopia (368.2). Diplopia occurs when a single object is perceived as two objects, “seeing double” or “double vision.” Diplopia results from injury to Cranial nerve 4 (trochlear nerve) resulting in lack of coordination of eye muscles.  

Eye and Ocular Adnexa Blindness and low vision (369) -visual impairment -visual disability -visual handicap ICD-9-CM Defined Levels of Visual Impairment - Table Blindness and low vision (369) contains a “Note” with important instructions. These instructions differentiate between “visual impairment,” “visual disability,” and “visual handicap” including definitions of all three. Definitions of blindness vary in different settings; this is explained in these instructions. A simple definition of blindness that may apply in all situations is: blindness is profound impairment. The table in ICD-9-CM follows these instructions and definitions and was based on the recommendations of the WHO Study Group on Prevention of Blindness, and of the International Council of Ophthalmology.

Eye and Ocular Adnexa Keratitis (370) Corneal opacity and other disorders of cornea (371) Disorders of conjunctiva (372) Inflammation of eyelids (373) Other disorders of eyelids (374) -Nystagmus Keratitis (370) is a large section in ICD-9-CM. Keratitis is inflammation of the cornea. Note that some of these codes have instructions “Code first underlying condition” and many have “Excludes.” Corneal opacity and other disorders of cornea (371) and Disorders of conjunctiva (372) follow. “Pink eye” (372.03) is an acute contagious conjunctivitis familiar to most of us. Inflammation of eyelids (373) and Other disorders of eyelids (374) follow. Entropion (374.0x) is infolding of the eyelid; ectropion (374.1x) is a rolling outward of the margin of the eyelid.   Other disorders of eye (379) end this section with codes to report disorders of sclera, vitreous and others. Nystagmus and other irregular eye movements (379.5) is part of this section. Nystagmus is rhythmical oscillation of the eyeballs that may be either pendular or jerky.

Ear and Mastoid Process Diseases of the Ear and Mastoid Process (380-389) Anatomy of ear -external -middle -internal Infectious disease Diseases of the Ear and Mastoid Process (380-389); lists codes to report conditions in this area. Disorders of the ear are listed as infection, neoplasias, injury, vertigo, hearing loss and congenital disorders. As with other sections of ICD-9-CM are listed according to anatomic site beginning with the external ear, moving to middle and inner ear and ending with hearing loss. Note that some ear infections are found in Infectious Disease chapter: also, you should report secondarily the infectious agent, if known. For example, Streptococcus pneumoniae is reported with (041.00).

Ear and Mastoid Process Table of Neoplasms -acoustic neuroma, vestibular schwannoma (225.1) Injury and Poisoning chapter Disorders of external ear (380) -infective otitis externa (380.1x) -Impacted cerumen (380.4) Neoplasias of the ear are listed in the Table of Neoplasms; as before, start in the Alphabetic Index to Diseases before going to the Tabular list. An interesting neoplasm in this area is a benign tumor of the acoustic nerve, the 8th cranial nerve. An Acoustic neuroma also called vestibular schwannoma is the most common neoplasm related to the ear. Even though it is benign, it results in headaches, problems related to balance and hearing and requires surgery. These tumors can become quite large – the size of a golf-ball or more before detection. Involving a cranial nerve, it is reported with (225.1) Benign neoplasm of cranial nerve. A result of surgery is complete loss of hearing on that side.   Codes to report injuries to the ear are found in the Injury and Poisoning chapter. Disorders of external ear (380) include, Infective otitis externa (380.1x). A more common name for many external ear infections is swimmers’ ear (380.12). Did you know there is also “beach ear” and “tank ear?” Another familiar problem is Impacted cerumen (380.4). There is a note explaining that earwax is only considered impacted if it is tightly packed and causes blockage of the ear canal, generally requiring instruments to remove.

Ear and Mastoid Process Nonsuppurative otitis media and Eustachian tube disorders (381) -acute (381.0x) -chronic (381.1x) Mastoiditis and related conditions (383) Nonsuppurative otitis media and Eustachian tube disorders (381) include commonly diagnosed otitis media. This common disorder can be acute (381.0x) and chronic (381.1x). In otitis media or middle ear infections, the infection occurs between the eardrum and the oval window. These infections can be difficult to cure and can be recurrent. Determination of the correct code will require good documentation by the provider for specific information besides acute or chronic, like if there is pus, viscous fluid or mucous. Frequently a “cold” or other upper respiratory infection allows bacteria access to the middle ear through the Eustachian tube. These chronic inflammations are sometimes treated with surgery with placement of tubes placed in the tympanic membrane to allow drainage of the infection from the middle ear. The use of this treatment is controversial. Chronic infections can result in decreased hearing.   Mastoiditis and related conditions (383) list codes for reporting conditions in this area. Recall that the mastoid process is posterior and inferior to the ear. The mastoid antrum (or nearly closed cavity) is a cavity in the mastoid process of the temporal bone lined with mucous membranes and continuous with the middle ear. Infections both acute (383.0x) and chronic (383.1x) of this area occur sometimes related to middle ear infections.

Ear and Mastoid Process Other disorders of tympanic membrane (384) - Perf. of tympanic membrane (384.2x) Vertiginous syndromes and other disorders of vestibular system (386) -Vertigo Otosclerosis (387) -Tinnitus (388.3x) Other disorders of tympanic membrane (384) includes Perforation of tympanic membrane (384.2x) also referred to as perforation or rupture of eardrum. This condition is related to a previously discussed problem, cerumen impaction. Some forget the advice, “never put anything smaller than your elbow in your ear” and try to clean ears with “Q-tips,” “Bobby pins” or even more dangerous instruments and perforate the eardrum.   Vertiginous syndromes and other disorders of vestibular system (386) is listed next. Vertigo is a sensation of spinning or whirling motion; sometimes this term is used loosely to describe dizziness. Described earlier, the vestibular system provides balance. There are many causes of vertigo including trauma, tumor (as previously mentioned, acoustic neuroma), or inflammation. If vertigo is listed as a symptom or the cause is unknown, report (780.4x). Meniere’s disease (386.0x) is characterized clinically by vertigo, nausea, vomiting, tinnitus (or ringing in the ears) and progressive hearing loss. It is caused by hydrops (or excessive fluid collection) in the endolymphatic duct. Otosclerosis (387) is a condition of the middle ear. Otosclerosis is new formation of spongy bone about the middle ear bone – stapes, and the oval window. Other disorders of ear (388), contains a condition previously mentioned, tinnitus (388.3x). Tinnitus is sensation of noises like ringing or whistling in the ears. There are many causes of tinnitus; one of the most common is aspirin ingestion.

Ear and Mastoid Process Hearing loss (389) -conductive hearing loss (389.0x) -Sensorineural hearing loss (389.1x) -Mixed conductive and sensorineural hearing loss (389.2x) Hearing loss (389) contains an important Layman’s note. It explains that the critical factors for making the determination on the appropriate hearing loss diagnosis. This includes the nature of the impairment, meaning whether the impairment is structural or functional and defines both. It also mentions whether the hearing loss involves one or both ears; and if it is conductive hearing loss, the site of the defect. The note contains more details explaining this.

CPT®: Eye and Ocular Adnexa Laser Surgery -laser is short for: light amplification stimulated emission of radiation -Carbon Dioxide -Nd:Yag -Argon Eye and Ocular Adnexa (65091-68899) is found in the Surgery section of CPT®. There are codes used to report procedures on the eye throughout CPT®. Most often these codes are reported by specialists. New techniques and use of lasers have allowed amazing procedures on eyes. A wonderful medical tool, particularly in the eye is laser surgery. Laser is an acronym for light amplification stimulated emission of radiation. These devices contain a substance whose atoms or molecules can be raised to a higher energy state, so light is emitted and focused in an intense narrow beam. Lasers can be used to burn, cut, coagulate, and ablate. There are a variety of types of lasers. CO₂ (carbon dioxide) lasers treat surface lesions vaporizing tissue. Nd:YAG (Nd is neodymium, a rare earth element; YAG is yttrium-aluminum-garnet) laser passes through unpigmented tissue and focuses sharply defined areas treating tissues at a deeper level than most other lasers. The argon laser is used primarily in ophthalmic procedures including retinal photocoagulation and trabeculoplasty; it coagulates blood and is extremely useful in the eye. This laser beam can be directed through a dilated pupil and the transparent eye structures to the back of the eye to coagulate vessels. We begin with more gross procedures.

CPT®: Eye and Ocular Adnexa Eyeball (65091-65290) -evisceration (65091,65093) -enucleatoin (65101-65105) -exenteration (65110-65114) Secondary Implant(s) Procedures (65125-65175) Eyeball (65091-65290) codes listed first include three ways to remove the eye. Malignancy is most often the reason for this dramatic surgery. Evisceration of ocular contents (65091-65093) is removal of the contents of the eyeball leaving the sclera, muscles and sometimes the cornea. There are two codes; the second reports evisceration with placement of an implant. Prosthetic eyes are extremely life-like, the only way you may be able to tell it is not real is failure of the pupil to change size. Ocular muscles can be attached, the implant eye moves. Evisceration is the least invasive of these procedures and is performed for less serious conditions. Enucleation of eye without implant (65101-65105) is next. Enucleation is removal of the entire eyeball without rupture; conjunctiva may remain. Codes specify if an implant is placed and if muscles are attached. Implant codes are for permanent implant placement – not for a temporary placement. Exenteration of orbit (65510-65114) is invasive surgery. Exenteration describes removal of contents of a cavity; the underlying condition is more serious or invasive. In this case, muscles, fat, and even bone (65112) are removed. Secondary Implant(s) Procedures (65125-65175) lists secondary procedures. In these situations, modification of an implant, secondary implant placement, reinsertion or removal of an implant may be required. In the case of exenteration for a more serious cancer, it may be best to allow healing of the area before placement of an implant.

CPT®: Eye and Ocular Adnexa Removal of Foreign Body (65205-65265) Anterior Segment (65400-66999) -Cornea (65400-65782) Opaque and opacity Removal or Destruction (65430-65600) Keratoplasty (65710-65757) Removal of Foreign Body (65205-65265) begins with parenthetical instructions worth reviewing. Some of these codes specify magnetic or nonmagnetic. This is important because metal objects frequently enter the eye via industrial accidents, they must be removed. Also, there are magnetic extraction methods. Repair of laceration (65270-65290) listings also begins with parenthetical instructions. A laceration is a torn or jagged wound caused by blunt trauma and technically not a “cut,” but this term is frequently used to describe this. Select these codes based on the location of the laceration, conjunctiva, cornea or sclera.   Anterior Segment (65400-66999) begins with Cornea (65400-65782). The cornea is the outermost and transparent layer of the eye. Opaque means impervious to light; opacity is lack of transparency. Both are problems if applied to eyes and vision. If the cornea is not clear it may require removal. Excision (65400-65426) lists a handful of codes and includes biopsy. Removal or Destruction (65430-65600) can be scraping, cauterization with chemicals or destruction by cryotherapy, photocoagulation or thermocauterization. Keratoplasty (65710-65757) comes next. Keratoplasty (kerato is cornea) is any surgical modification of the cornea and often includes the insertion of a piece of cornea from another location. There are instructions at the beginning of this section regarding reporting grafts and their preparation for corneal transplant. There is an add-on code (65757) for backbench preparation on the allograft.

CPT®: Eye and Ocular Adnexa Anterior Chamber (65800-66030) Incision (65800-65880) Goniotomy (65820) Trabeculotomy ab externo (65850) -Schlemm’s canal Anterior Sclera (66130-66250) -Excision of lesion, sclera (66130) Anterior Chamber (65800-66030) listings are next. Incision (65800-65880) starts with paracentesis. Paracentesis is passage into a cavity of a hollow instrument to remove fluid, in this case aqueous humor. Goniotomy (65820) is surgical opening of the trabecular meshwork, usually in congential glaucoma and is therefore performed on infants or children. Included are parenthetical instructions regarding use of modifier 63 and other instructions. Trabeculotomy ab externo (65850) involves cutting from outside the eye inward to reach Schlemm’s canal, the trabecular meshwork, and the anterior chamber. Also known as non-penetrating trabeculectomy; ab externo is “from the outside.” Following are trabeculoplasty and severing or lysis of adhesions of the anterior segment.   Anterior Sclera (66130-66250) is divided into Excision, Aqueous Shunt and Repair or Revision. It begins with Excision of lesion, sclera (66130) and most of the procedures aim at correcting pressure problems in the eye.

CPT®: Eye and Ocular Adnexa Iris, Ciliary body (66500-66770) Iriditiomy (66761-66770) Lens (66820-66940) -cataracts Intraocular Lens Procedures (66982-66986) Iris, Ciliary Body (66500-66770) is grouped by Incision, Excision, Repair, and Destruction. Recall from earlier; ciliary bodies are important suspensory ligaments of the lens. As explained previously, the lens is soft, changes in tension of the ciliary bodies changes the shape of the lens changing refraction. Iridotomy is transverse division of some of the fibers of the iris. There are two codes listing these procedures (66761-66770). Lens (66820-66940) is grouped by Incision, and Removal. Cataract removal is the primary procedure in this category. There are instructions for review explaining components of these procedures reported with the codes. Pars plana approach (66852) is a open procedure to get to the back to the retina or vitreous. Intraocular Lens Procedures (66982-66986) lists five codes. These codes report procedures on the lens and its capsule.

CPT®: Eye and Ocular Adnexa Posterior Segment (67005-67999) Vitreous (67005-67043) Implantation of intravitreal drug delivery system (67027) Retina or Choroid (67101-67229) Posterior Sclera (67250-67225) Posterior Segment (67005-67999) begins with Vitreous (67005-67043). These codes report removal or aspiration of vitreous, the liquid in the posterior segment of the eye. Implantation of intravitreal drug delivery system (67027) reports procedures for drug delivery devices. There is a good picture in CPT®, the pars plana approach mentioned above is demonstrated. Retina or Choroid (67101-67229) is grouped by Repair, and Repair of Retinal Detachment, and Prophylaxis. Retinal detachment was described earlier. Scleral buckling involves placing a silicone band around the globe to “buckle” it following treatment of the detachment to aid in healing (67107). Release of encircling material (67115) reports removal of the band. Posterior Sclera (67250-67225) contains two codes for repair.

CPT®: Eye and Ocular Adnexa -strabismus horizontal (67311-67312) vertical (67314-67316) transposition (67320) Orbit (67400-67599) Ocular Adnexa (67229-67999) deals mainly with extraocular muscles. A coordinated effort of all muscles is required for intricate eye movements; think of a batter attempting to hit 98 mph fastball! Strabismus is a lack of parallelism of the visual axes of the eyes. Strabismus surgery in this section is grouped into that performed for the horizontal (67311-67312) and vertical (67314-67316) muscles. With the transposition procedure (67320) the superior rectus muscle (one of the extraocular muscles) is transposed or moved. Adjustable sutures can be placed in strabismus surgery (67335). This section of CPT® contains valuable pictures worth reviewing to make sense of these procedures.   Orbit (67400-67599) lists Exploration, Excision, Decompression codes. There are several parenthetical instructions.

CPT®: Eye and Ocular Adnexa Eyelids (67700-67999) Hordeolum externum Excision of chalazion; single (67800) Repair of brow ptosis (67900) Blepharoptosis (67901-67908) Eyelids (67700-67999) is grouped by Incision, Excision, Destruction, Tarsorrhaphy, Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion, Entropion) and Reconstruction. Have you ever had a hordeolum externum? Actually, probably you have; it is the inflammation of the sebaceous gland of the eyelash commonly known as a stye and feels like there is something in your eye. Drainage of an abscess of the eyelid (67700), blepharotomy is listed first. Excision of chalazion; single (67800) is removal of a chronic inflammatory granuloma of meibonian gland of the eyelid. Following codes report more lesions or other “lids.” Repair of brow ptosis (67900) is repair of a sinking or drooping eyelid; blepharoptosis is skin hanging over the free border of the eyelid, repair of this is 67901-67908.

CPT®: Eye and Ocular Adnexa Conjunctiva (68020-68899) -conjunctivoplasty Lacrimal System (68400-68899) Excision of lacrimal sac (68520) (dacryocystectomy) Conjunctiva (68020-68899) is grouped by Incision and Drainage, Excision and/or Destruction, Injection, Conjunctivoplasty, Other procedures and Lacrimal System. Conjuctivoplasty often includes placement of a graft at the same time. Read these codes carefully for specific procedures. Lacrimal System (68400-68899) is grouped by Incision, Excision, Repair and Other Procedrues. Lacrimal glands secrete lacrimal fluid which serves to clean the eye and moisturize the cornea and conjunctiva. Blinking spreads the fluid moisturizing these structures; fluid is pushed toward the medial angle of the eye to accumulate in the lacrimal lake from which it drains to the lacrimal sac and finally to the nasopharynx and is swallowed. Excision of lacrimal sac (dacryocystectomy) (68520) can be required for infection or tumor.

CPT®: Eye and Ocular Adnexa Medicine section Ophthalmology (92002-92499) -General Ophthalmology Services (92002-92014) -Special Ophthalmological Services -Contact Lens Services -Spectacle Services (Including Prosthesis for Aphakia) Listed in the Medicine section of CPT® under Ophthalmology (92002-92499) are codes reporting services for General Ophthalmology Services, Special Ophthalmological Services, Contact Lens Services, and Spectacle Services (Including Prosthesis for Aphakia). There are instructions at the beginning of the section defining the difference between Intermediate and Comprehensive ophthalmological services. There are also instructions regarding Special ophthalmological services. The first codes listed here are based on new and established patient criteria, and level of service provided; they are E/M codes. This can be confusing! At the beginning of CPT® the first codes listed are E/M codes. Most E/M codes are in the 99000 range, but placed at the front of CPC®. General Ophthalmological Services (92002-92014) lists 4 codes for New Patient and Established Patient. Definitions for new and established patients are important; a new patient has not received professional services by the provider or one in the same group within the past three years. An established patient has.  

CPT®: Eye and Ocular Adnexa Medicine section Special Ophthalmological Services (92015-92140) Determination of refractive state (92015) Ophthalmoscopy (92225-92260) -direct -indirect Special Ophthalmological Services (92015-92140) goes beyond the services included under general services. These services are reported in addition to general ophthalmological services. With these services, a special evaluation of part of the visual system is made which goes beyond services included in general ophthalmological services or in which special treatment is given. Determination of refractive state (92015) is an eye exam. If refractive lenses (or glasses) are required, this is included in this code. This includes all of the specifications of the lenses. Ophthalmoscopy (92225-92260) is examination of the fundus or posterior portion of the interior of the eye. It can be direct (using an ophthalmoscope) or indirect (doctor wears an indirect ophthalmoscope and holds a lens separately in the hand close to the patient’s eye). There is a very helpful illustration in CPT®.

CPT®: Eye and Ocular Adnexa Medicine section Contact Lens Services (92310-92326) Spectacle Services (Including Prosthesis for Aphakia) (92340-92371) -aphakia (92353-92358) Contact Lens Services (92310-92326) lists codes for the fitting of contact lenses. Contact lens prescription and specification is not part of general ophthalmological services. This service includes fitting, instruction and training that may require revision and even refitting. There are instructions at the beginning of this section to review.   Spectacle Services (Including Prosthesis for Aphakia) (92340-92371) lists fitting of spectacles. The “medical” definition of spectacles is lenses set in a frame that holds them in front of the eyes, used to correct errors of refraction or to protect the eyes. If that sounds like “glasses,” you are correct. Aphakia is absence of lens of the eye. A spectacle prosthesis may be inserted for aphakia (92353-92358). Other codes in this section mention “except for aphakia” for lenses for glasses. Included in the code is measurement of anatomical facial characteristics, writing of lab specifications and adjustment of the spectacles. The prescription is part of the service

CPT®: Auditory System Auditory System (69000-69979) Removal foreign body from external auditory canal (69200-69205) - both ears (69210) Auditory System (69000-69979) follows eye in the surgery section of CPT® Other codes related to the ear are listed in 90000.   The listings begin anatomically with the External Ear. Under the removal listings, Removal foreign body from external auditory canal (69200-69205), codes are chosen based on use of anesthesia. Commonly used, Removal impacted cerumen (separate procedure), 1 or both ears (69210) reports removal of earwax described earlier. Note that it is the same code whether one or both ears are cleaned.

CPT®: Auditory System Middle Ear (69400-69799) Tympanostomy (69433-69436) Mastoidectomy; complete (69502) -modified radical (69505) -radical (69511) Tympanoplasty (69635-69646) Middle Ear (69400-69799) is a larger section of codes. It is grouped by Introduction, Incision, Excision, Repair and Other Procedures. Tympanostomy (69433-69436) is demonstrated very well with an illustration showing the tubes. Tympanostomy is synonymous with myringotomy which is creating a passageway through the tympanic membrane. Discussed earlier, placement of tubes in ears has become controversial. Previously children with recurrent middle early infections received “tubes” to help drain the ears and prevent recurrent infections. For many, it not only prevented repeated visits to the E.R. and pediatrician offices, it saved their hearing. Repeated infections cause scarring and damage to delicate structures in the middle ear impacting hearing. Mastoidectomy; complete (69502) is removal of the mastoid bone. Malignancy or extremely serious infection necessitate this procedure. Listed next are more extreme procedures, modified radical (69505) and radical (69511). Repair of the tympanic membrane, tympanoplasty (69635-69646) codes contain notes and instructions to be reviewed carefully. CPT® contains a good illustration of this in the Repair section of the middle ear.

CPT®: Auditory System Inner Ear (69801-69949) Labyrinthectomy (69905) Temporal Bone, Middle Fossa Approach (69950-69979) Microsurgery Inner Ear (69801-69949) is grouped by Incision and/or Destruction, Excision, Introduction and Other Procedures. Few codes are listed here. These are extremely small structures. An excision code (69905) labyrinthectomy reports removal of the labyrinth in the middle ear. This is a very small, well protected structure, very difficult to get to.   Temporal Bone, Middle Fossa Approach (69950-69979) contains five codes. Decompression usually refers to a nerve that is under pressure. Decompression procedures are performed to relive the pressure. At the end of this section is a long discussion in green writing (new this year) regarding the Operating Microscope. Microsurgery is of critical importance regarding the procedures performed in the ear and on the eyes. These instructions are worth review

CPT®: Auditory System Medicine Section Special Otorhinolaryngolocic Services (92502-92700) Otolaryngologic examination under general anesthesia (92502) Vestibular Function Tests (92531-92548) Audiologic Function Tests with Medical Diagnostic Evaluation (92559-92597) Listed in the Medicine section of CPT® under Special Otorhinolaryngologic Services (92592-92700) lists services: Vestibular Function Tests, Without Electrical Recording; Vestibular Function Tests, With Recording (eg, ENG); Audiologic Function Tests; and Evaluative ant Therapeutic Services. At the beginning of the section are brief instructions as in the eye section. Special otorhinolaryngologic services are those diagnostic and treatment services that are not included in the E/M services and are reported separately using these codes (92502-92700). There are services such as otoscopy and removal of non-impacted cerumen that are reported as E/M codes and not reported separately. Otolaryngologic examination under general anesthesia (92502) is obviously not a routine exam due to the use of general anesthesia, and is special.   Vestibular Function Tests (92531-92548); lists codes used to report testing of vestibular function listing 4 codes. Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests)(92533) is a test for nystagmus. Cooled and heated water is injected into the external ear canal successively and will produce nystagmus in an established pattern in normal patients. Patients with abnormalities will react differently. Vestibular Function Tests, With Recording (eg, ENG) (92540-92548) with tests that do produce a recording. The previous section mentioned “without testing” can be difficult because results are subjective and may be hard to interpret. Audiologic Function Tests with Medical Diagnostic Evaluation (92559-92597) services are performed by a physician or audiology technician to diagnose hearing loss etiology. These procedures are also called audiometric testing. All tests are considered bilateral, if only one ear is tested, apply modifier 52. Audiometric testing of groups (92559) requires specifying test(s) used.

CPT®: Auditory System Medicine Section Evaluative and Therapeutic Services (92601-92633) Cochlear implants Evaluative and Therapeutic Services (92601-92633) is a large section of codes. Cochlear implants are very helpful to many children; codes may be divided by age, seven years or younger/older. This is especially important for young children because hearing is so vital to development of speech. There is controversy regarding the need for unilateral or bilateral implants in children. Many of the procedures listed in this section evaluate swallowing and functions related to speech

HCPCS and Modifiers HCPCS Level II - injectible or implantable drug -prostheses, visual aids, contact lenses, glasses and hearing aids Modifiers -50 Bilateral procedure -RT, LT HCPCS Level II  These codes are used to report the supply of injectible or implantable drugs used in the treatment of ear and eye disorders. Also, prostheses, visual aids, contact lenses, glasses and hearing aids are listed here. Glaucoma screening codes for those participating in the Physician Quality Reporting Initiative (PQRI) are found in the temporary G codes. The table of drugs lists drugs contains eye and ear medicines used. Modifiers Because eyes and ears are bilateral organs, identifying a procedure as bilateral (50) or identifying laterality (RT and LT) becomes very important to payers.

The End