Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CHAPTER 22 EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE

2 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Eye and Ocular Adnexa ( ) Terminology extremely importantTerminology extremely important –Code descriptions often vary only slightly (Cont’d…) Figure: 22.1

3 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Eye and Ocular Adnexa ( ) (…Cont’d) Codes divided anatomically, examples:Codes divided anatomically, examples: –Eyeball –Conjunctiva –Anterior Segment –Posterior Segment –Ocular Adnexa Some codes specifically for patients previously operated onSome codes specifically for patients previously operated on(Cont’d…)

4 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. (…Cont’d) Much bundlingMuch bundling –Example: Subheading Posterior Segment, Prophylaxis category notes indicate “The following descriptors intended to include all sessions in defined treatment period.”“The following descriptors intended to include all sessions in defined treatment period.” Eye and Ocular Adnexa ( )

5 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Eyeball ( ) Removal of the Eye report:Removal of the Eye report: –Evisceration (65091, 65093) Removal of contents of globeRemoval of contents of globe –Enucleation ( ) Removal of eye, leaving orbital structures intactRemoval of eye, leaving orbital structures intact –Exenteration ( ) Removal of eye, adnexa, part of bony orbitRemoval of eye, adnexa, part of bony orbit Associated skin grafting reported separately (15120/15121, 15260/15261)Associated skin grafting reported separately (15120/15121, 15260/15261)

6 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Removal of Foreign Body ( ) Extensive notesExtensive notes Removal from external or intraocularRemoval from external or intraocular Slit lampSlit lamp –Microscope with high-intensity light source –Focuses long narrow beam of light –Different codes for with/without slit lamp –Example: 65220, foreign body removal without slit lamp; 65222, foreign body removal with slit lamp65220, foreign body removal without slit lamp; 65222, foreign body removal with slit lamp

7 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Anterior Segment ( ) Includes:Includes: –Cornea –Anterior Chamber –Anterior Sclera –Iris, Ciliary Body –Lens –Intraocular Lens Procedures –Other Procedures

8 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Cornea Keratoplasty: Repair of corneaKeratoplasty: Repair of cornea Penetrating keratoplasty: Full thickness of cornea removedPenetrating keratoplasty: Full thickness of cornea removed –Replaced with donor cornea Aphakia: Absence of lens of eyeAphakia: Absence of lens of eye Pseudophakia: Presence of artificial lens after cataract surgeryPseudophakia: Presence of artificial lens after cataract surgery

9 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Anterior Chamber ( ) Paracentesis: Removal of fluidParacentesis: Removal of fluid –Needle inserted into anterior chamber and fluid withdrawn Diagnostic (65800)Diagnostic (65800) Therapeutic ( )Therapeutic ( ) Goniotomy: Surgical procedure using goniolens to view eye (65820)Goniotomy: Surgical procedure using goniolens to view eye (65820) –Usually for congenital glaucoma Synechiae (adhesions)Synechiae (adhesions) –Posterior synechiae: Adhesions iris to lens –Anterior synechiae: Adhesions iris to cornea

10 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Anterior Chamber ( ) (…Cont’d) Trabeculectomy ab externo (e.g., 65850)Trabeculectomy ab externo (e.g., 65850) –Involves trabecular meshwork Iris-scleral junction, drains aqueous humorIris-scleral junction, drains aqueous humor –Surgery reshapes or punctures the meshwork as a treatment for glaucoma or trauma

11 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Iris, Ciliary Body ( ) Iridotomy performed for removal of:Iridotomy performed for removal of: –Lesion (66600) –Treatment of glaucoma (66625, 66630) –Laser iridotomy (66761) –Photocoagulation (66762)

12 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Lens ( ) CataractsCataracts –Nuclear cataract: Most common Center of lens (nucleus)Center of lens (nucleus) Due to aging processDue to aging process –Cortical cataract: Forms in lens of cortex and extends outward Common in diabeticsCommon in diabetics –Subcapsular cataract: Forms at back of lens Assigned based on type of procedure performedAssigned based on type of procedure performed –Intracapsular (ICCE) –Extracapsular (ECCE) (Cont’d…)

13 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Lens (…Cont’d) Removal and lens placement ( )Removal and lens placement ( ) –Extracapsular cataract extraction (ECCE), partial removal Removes hard nucleus in 1 piece and soft cortex in multiple piecesRemoves hard nucleus in 1 piece and soft cortex in multiple pieces –Intracapsular cataract extraction (ICCE), total removal Removes lens and capsule in 1 pieceRemoves lens and capsule in 1 piece –Phacoemulsification Small incision into eye, introduction of probeSmall incision into eye, introduction of probe High frequency waves fragment cataractHigh frequency waves fragment cataract Lens placed through same small incisionLens placed through same small incision

14 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Posterior Segment ( ) Codes include:Codes include: –Vitreous procedures for removal of vitreous humor from the eye –Repair of retinal detachment –Destruction lesion of retina or choroid

15 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Extraocular Muscles ( ) Strabismus SurgeryStrabismus Surgery –Connects muscle misalignment –Horizontal muscles ( ) Move the eye side to sideMove the eye side to side –Vertical muscles ( ) Move the eye up and downMove the eye up and down –Codes are divided by the type of repair and number of muscles repaired

16 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Eyelid ( ) Blepharotomy (67700)Blepharotomy (67700) –Incision into eyelid for drainage of abscess BlepharoplastyBlepharoplasty –Repair of eyelid –Codes in Integumentary System ( ) –Codes in Eye and Ocular Adnexa (67916, 67917, 67923, 67924) Selection of code depends on technique used for repairSelection of code depends on technique used for repair Figure: 22.3

17 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Eyelid Modifiers E1-E4E1-E4 E1—upper left eyelidE1—upper left eyelid E2—lower left eyelidE2—lower left eyelid E3—upper right eyelidE3—upper right eyelid E4—lower right eyelidE4—lower right eyelid

18 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Auditory System ( ) Codes divided byCodes divided by –External Ear ( ) –Middle Ear ( ) –Internal Ear ( ) –Temporal Bone, Middle Fossa Approach ( ) Outer and middle ear function is conduction of sound waves through the earOuter and middle ear function is conduction of sound waves through the ear Inner ear contains structures that receive the auditory waves and relay them to the brainInner ear contains structures that receive the auditory waves and relay them to the brain –Right ear—AD –Left ear—AS –Both ears—AU Operating Microscope (69990)Operating Microscope (69990)

19 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Divisions of Auditory System External, middle, and internal earExternal, middle, and internal ear Figure: 22.10

20 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Auditory System Further divisions on procedure:Further divisions on procedure: –Incision –Excision –Removal, e.g., foreign body –Repair –Other

21 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. External Ear ( ) Incision: Drainage of abscess or hematomaIncision: Drainage of abscess or hematoma –Simple, –Complicated, Excision: BiopsyExcision: Biopsy –External ear, –External auditory canal, –Excision of external ear, partial/complete, 69110, 69120

22 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Removal of Foreign Body Based on with/without general anesthesiaBased on with/without general anesthesia –69200, Impacted cerumenImpacted cerumen –One or both ears –69210

23 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Repair OtoplastyOtoplasty –For protruding ears –May or may not decrease external ear size –Add -50 for both ears

24 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Eustachian tube connects middle ear to back of throat for drainageEustachian tube connects middle ear to back of throat for drainage –Fluid collects in middle ear when tube malfunctions –Prevents air from entering middle ear and pressure builds Surgical interventionSurgical intervention –Myringotomy (incision into tympanic membrane) relieve pressure and drain pus –Tympanostomy (incision and placement of PE tube (pressure equalization) repair of eardrum and hearing mechanism Myringotomy included in a tympanostomy (tubes)Myringotomy included in a tympanostomy (tubes) Middle Ear ( )

25 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Middle Ear ( ) CanalplastyCanalplasty –Reconstruction of external auditory canal –Codes based on stenosis or congenital defect –Caution: Canalplasty bundled into some middle ear repair codes For example For example

26 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Inner Ear, Incision and/or Destruction ( ) Labyrinthotomy: Surgical incision into the cavelike structure (labyrinth) of inner earLabyrinthotomy: Surgical incision into the cavelike structure (labyrinth) of inner ear If pressure builds within labyrinth, may result in:If pressure builds within labyrinth, may result in: –Vertigo –Ringing –Hearing loss, etc , = with/without mastoidectomy69801, = with/without mastoidectomy

27 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Excision ( ) LabyrinthectomyLabyrinthectomy Incus and stapes are removedIncus and stapes are removed Codes are based on approach as:Codes are based on approach as: –Transcanal –Postauricular (behind ear) 69910

28 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Introduction (69930) Cochlear device ImplantCochlear device Implant Computerized deviceComputerized device Restores partial hearingRestores partial hearing Receiver on outside of skin, behind ear, over the site of transmitterReceiver on outside of skin, behind ear, over the site of transmitter Transmitter implanted under skinTransmitter implanted under skin Sound processor connected to an electrode implanted in cochlearSound processor connected to an electrode implanted in cochlear

29 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Temporal Bone, Middle Fossa Approach ( ) Surgical approach used with:Surgical approach used with: Repair vestibular labyrinth nerves (69950)Repair vestibular labyrinth nerves (69950) Decompress facial nerve (69955)Decompress facial nerve (69955) Decompress internal auditory canal (69960)Decompress internal auditory canal (69960) Removal of neoplasm from temporal bone (69970)Removal of neoplasm from temporal bone (69970)

30 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Operating Microscope (+69990) Used with procedures using microsurgical techniquesUsed with procedures using microsurgical techniques Code in addition to primary procedure performedCode in addition to primary procedure performed –Unless primary procedure description includes microsurgical techniques –Example: Free fascial flap with microvascular anastomosis –Note that following is the statement: “(Do not report code in addition to code 15758)”“(Do not report code in addition to code 15758)”

Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 22 EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE