Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 27 EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Eye and Ocular Adnexa ( ) Terminology extremely important –Code descriptions often vary only slightly (Cont’d…) Figure: 27.1

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Eye and Ocular Adnexa ( ) (…Cont’d) Codes divided anatomically, examples: –Eyeball –Conjunctiva –Anterior Segment –Posterior Segment –Ocular Adnexa Some codes specifically for patients previously operated on (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Eye and Ocular Adnexa ( ) (…Cont’d) Much bundling –Example: Subheading Posterior Segment, Prophylaxis category notes indicate “The following descriptors intended to include all sessions in defined treatment period.”

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Eyeball ( ) Removal of the Eye report: –Evisceration (65091, 65093) Removal of contents of globe –Enucleation ( ) Removal of eye, leaving orbital structures intact –Exenteration ( ) Removal of eye, adnexa, part of bony orbit Associated skin grafting reported separately (15120/15121, 15260/15261)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Removal of Foreign Body ( ) Extensive notes Removal from external or intraocular Slit 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 lamp

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Anterior Segment ( ) Includes: –Cornea –Anterior Chamber –Anterior Sclera –Iris, Ciliary Body –Lens –Intraocular Lens Procedures –Other Procedures

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Cornea Keratoplasty: Repair of cornea Penetrating keratoplasty: Full thickness of cornea removed –Replaced with donor cornea Aphakia: Absence of lens of eye Pseudophakia: Presence of artificial lens after cataract surgery

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Anterior Chamber ( ) Paracentesis: Removal of fluid –Needle inserted into anterior chamber and fluid withdrawn Diagnostic (65800) Therapeutic ( ) Goniotomy: Surgical procedure using goniolens to view eye (65820) –Usually for congenital glaucoma Synechiae (adhesions) –Posterior synechiae: Adhesions iris to lens –Anterior synechiae: Adhesions iris to cornea (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Anterior Chamber ( ) (…Cont’d) Trabeculectomy ab externo (e.g., 65850) –Involves trabecular meshwork Iris-scleral junction, drains aqueous humor –Surgery reshapes or punctures the meshwork as a treatment for glaucoma or trauma

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Iris, Ciliary Body ( ) Iridectomy performed for removal of: –Lesion (66600) –Treatment of glaucoma (66625, 66630) –Laser iridotomy/iridectomy (66761) –Photocoagulation (66762)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Lens ( ) Cataracts –Nuclear cataract: Most common Center of lens (nucleus) Due to aging process –Cortical cataract: Forms in lens of cortex and extends outward Common in diabetics –Subcapsular cataract: Forms at back of lens Assigned based on type of procedure performed –Intracapsular (ICCE) –Extracapsular (ECCE) (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Lens (…Cont’d) Removal and lens placement ( ) –Extracapsular cataract extraction (ECCE), partial removal Removes hard nucleus in 1 piece and soft cortex in multiple pieces –Intracapsular cataract extraction (ICCE), total removal Removes lens and capsule in 1 piece –Phacoemulsification Small incision into eye, introduction of probe High frequency waves fragment cataract Lens placed through same small incision

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Posterior Segment ( ) Codes include: –Vitreous procedures for removal of vitreous humor from the eye –Repair of retinal detachment –Destruction lesion of retina or choroid

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Extraocular Muscles ( ) Strabismus Surgery –Corrects muscle misalignment –Horizontal muscles ( ) Move the eye side to side –Vertical muscles ( ) Move the eye up and down –Codes are divided by the type of repair and number of muscles repaired

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Eyelids ( ) Blepharotomy (67700) –Incision into eyelid for drainage of abscess Blepharoplasty –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 repair Figure: 27.3

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Eyelid Modifiers E1-E4 E1—upper left eyelid E2—lower left eyelid E3—upper right eyelid E4—lower right eyelid

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Auditory System ( ) Codes 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 ear Inner ear contains structures that receive the auditory waves and relay them to the brain Operating Microscope (69990)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Divisions of Auditory System External, middle, and internal ear Figure: 27.10

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Auditory System Further divisions on procedure: –Incision –Excision –Removal, e.g., foreign body –Repair –Other

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 External Ear ( ) Incision: Drainage of abscess or hematoma –Simple, –Complicated, Excision: Biopsy –External ear, –External auditory canal, –Excision of external ear, partial/complete, 69110, 69120

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Removal of Foreign Body Based on with/without general anesthesia –69200, Impacted cerumen –One or both ears –69210

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Repair Otoplasty –For protruding ears –May or may not decrease external ear size –Add -50 for both ears

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Middle Ear ( ) Eustachian 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 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) (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Middle Ear ( ) Canalplasty –Reconstruction of external auditory canal –Codes based on stenosis or congenital defect –Caution: Canalplasty bundled into some middle ear repair codes For example (…Cont’d)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 Inner Ear, Incision and/or Destruction ( ) Labyrinthotomy: Surgical incision into the cavelike structure (labyrinth) of inner ear If pressure builds within labyrinth, may result in: –Vertigo –Ringing –Hearing loss, etc (transcanal)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Excision ( ) Labyrinthectomy Incus and stapes are removed Codes are based on approach as: –Transcanal –Postauricular (behind ear) 69910

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Introduction (69930) Cochlear device implant Computerized device Restores partial hearing Receiver on outside of skin, behind ear, over the site of transmitter Transmitter implanted under skin Sound processor connected to an electrode implanted in cochlea

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Temporal Bone, Middle Fossa Approach ( ) Surgical approach used with: Repair vestibular labyrinth nerves (69950) Decompress facial nerve (69955) Decompress internal auditory canal (69960) Removal of neoplasm from temporal bone (69970)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Operating Microscope (+69990) Used with procedures using microsurgical techniques Code 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)”

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Conclusion CHAPTER 27 EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE