CATARACT SURGERYINDICATIONS FOROPERATION: The patient is a 73year-old with painless progressiveloss of vision in the right eye. Thepatient was noted to have difficultywith activities of daily living due tothe decreased vision. The risks,benefits and alternatives to cataractsurgery were explained to the patientto include hemorrhage, infection,inflammation, residual refractiveerror, need for additional surgery, lossof vision, loss of eyeball, death,and/or complications from cataractsurgery. The patient desired toproceed with the operation to helpimprove the vision in the right eye.
Description of ProcedureThe patient was correctly identified in the preoperative holding area where consent was obtained,and the IV access was placed by anesthesia. The patient was then brought to the operating roomand placed in the supine position on the operating eye bed. Viscous lidocaine 2% jelly was placedin the right eye for anesthetic, and it was then prepped and draped in the usual sterile fashion forophthalmic surgery.A Lieberman wire lid speculum was used to hold the eyelid open. A Thornton ring andparacentesis blade was used to create a paracentesis at the 2:30 position. Viscoelastic wasinjected into the anterior chamber. The Phacoemulsification incision knife was used to create aPhaco incision at the 11:30 position, and a cystotome needle was used to create a capsulorrhexisflap. A continuous curvilinear capsulorrhexis was completed using the Utrata forceps, andhydrodissection was carried out with sterile BSS on a blunt-tipped cannula. The nucleus was thensculpted and removed with the Phacoemulsification handpiece and a Chang nucleus manipulator.A stop-and-chop technique was used. After the nucleus was removed, the remaining cortex wasaspirated with the IA handpiece, and Provisc and viscoelastic were used to inflate the posteriorcapsule. The AcrySof lens implant, power 24.0 diopters, model SN60WF was inserted with theMonarch Injector System. It was noted to open nicely within the bag. The remaining viscoelasticwas removed with the I&A handpiece and sterile BSS was used to reinflate the eye to aphysiologic pressure. The wounds were then tested with dry Weck-cel sponges and found to bewatertight. One drop of prednisolone acetate 1% and 1 drop of Vigamox were applied to the eyepostoperatively. The lid speculum was removed, and the drapes were then removed. A clearplastic eye shield was then taped in place over the operative eye. The patient was then brought tothe recovery room in good condition. The patient will follow up with us tomorrow in our office andinstructions were given for postoperative medication.
Evaluation of Coding• An operative report and video demonstration was sent out to 200 healthcare professionals asking their input on the coding for the procedure “phacoemulsification cataract extraction with intraocular lens implantation of the right eye.” Of the 200 requests for input, a sufficient sample was taken from the inputs to draw my conclusion. This is one of the first and easiest outpatient surgery procedures a medical coder will learn to code using ICD-9 CM/PCS. The purpose of this project is to demonstrate how the coding of even the simplest coding scenarios can prove challenging in both ICD-9 CM/PCS and ICD-10 CM/PCS when the coding guidelines are not known and the documentation is incomplete. It would appear that all relevant information was provided to result in the correct diagnosis and procedure code assignments depicted in the scenario. Unfortunately, this proves not to be the case. Congratulations to those who found the discrepancies and were able to identify them.• First, let us begin with the ICD-9 CM and ICD-10 CM assignment codes, 366.9 and H26.9. Based on some of your responses, the coder was left to assume that the cataract was senile based on the patient’s age. Therefore, it was suggested that the cataract be coded to senile. This is a documentation issue that should be addressed with the physician. The physician should be informed that the type of cataract should be documented so that the hospital can maintain quality control of data for use within and outside the hospital, ensure accurate coding, and maximum reimbursement. ICD-10 CM was developed to have as a feature greater specificity and clinical detail which assist in providing information for clinical decision making and outcome research. Documentation is the key to the success of this outcome.
Evaluation of Coding• Next, the ICD-9 and ICD-10 PCS assignment codes received a variety of responses. The one that stands out the most is the ICD-10 PCS coding. In the scenario, ICD-10 PCS codes 08DJ3ZZ and 08RJ3JZ were used. The majority agreed with this code assignment with others believing the procedure should require one ICD-10 PCS code. The latter is the correct response. In educating your coders, remind them that it is the natural inclination to assign two codes because there are two codes assigned in ICD-9. The procedure should be coded to replacement only, not as an extraction and insertion. ICD-10 defines replacement as the putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body. Examples include: phacoemulsification of cataract with intraocular lens implantation; hip hemiarthroplasty, open; and excision of abdominal aorta with Gore-Tex graft replacement, open. Education in the area of root operations and what they entail is the key to accurate code assignment.• Lastly, some were confident enough to question the CPT assignment. Although, the CPT code is not the focus of the coding, it does lead to another area that can affect code assignment and that is the coder’s individual interpretation. The CPT code 66982 is described as the extracapsular cataract removal with insertion of intraocular lens prosthesis, manual or mechanical technique, complex requiring devices or techniques not generally used in routine cataract surgery or performed on patients in the ambylogenic development stage. In the scenario, a Monarch Injector System was used during the procedure, some may argue that the Monarch Injector System is not routinely used in the procedure. The hospital should establish what is considered complex in the coding of cataract extraction and lens insertion.• I hope this project has outlined the importance of continued education and training in the areas of ICD-10 CM/PCS coding and clinical documentation improvement. The continual practice and policy implementation of guidelines surrounding these issues should be ongoing and at the forefront of every health care providers organizational strategy.