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Quick Coding : Created by Medycoding

 

 

Dont need to read the work description line by line, do quick coding by checking the necessary documentation in your report.

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CPT 66984 : Correct Coding​​

CPT  Code description:

66984 [Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation ]

​Coding short description​

  1. Wire Eyelid Speculum Placed.

  2. Paracentesis done

  3. Injected Lidocaine

  4. Corneear Incision using Keratome blade.

  5. Circular Capsulorrhexis performed.

  6. Cortical cleaving hydrodissection was completed. [removing of posterior capsule attachment to the lens]

  7. In-situ phacoemulsification of the lens nucleus and epinuclear material was performed.

  8. Residual cortical material removed.

  9. A new Lens implanted .​ ​​​

CPT 52649 : Correct Coding​​

CPT  Code description:

52649 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)

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Morcellation: Fragmentation of larger tissues into smaller pieces for easy removal.

Meatotomy: A surgical procedure in which an incision is made to enlarge a meatus

​Coding short description​

  1. Resectoscope is inserted.

  2. Holium Laser device is inserted and target prostate tissue is resected.

  3. The prostate or the target big prostate adenoma gets cut into smaller pieces (morcellation) that can easily be removed from the body. For this purpose, a commercially available Morcellator instrument is used

  4. Once the procedure is finished a catheter is inserted and the patient is transferred to the recovery room.

CPT 59151 : Correct Coding​​

CPT  Code description:

59151 Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy.

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Oophorectomy: The surgical removal of one or both ovaries.

Meatotomy: A surgical procedure in which an incision is made to enlarge a meatus

 

Ectopic pregnancy: An ectopic pregnancy is a medical condition in which a fertilized egg implants and grows outside the main cavity of the uterus. This abnormal implantation most commonly occurs in the fallopian tubes (tubal pregnancy), but it can also occur in other areas like the cervix, ovaries, or abdominal cavity.

​Coding short description​

  1. Small cut is made in abdomen.

  2. The provider insufflates the abdomen iwth carbon dioxide.

  3. Trocar or other surgical tool is inserted.

  4. If robotic surgery is done, then robot may be docked.

  5. Once provider completes his inspection, the provider infiltrates the lining of the fallopian tube or top part of the uterus with vasopressin, a drug that reduces blood loss.

  6. He then aspirates any products of conception, blood clots, or free blood that may be present. Since there is damage to the tube or ovary, the provider removes the ovary and or the fallopian tube.

CPT 47490 : Correct Coding​​

CPT  Code description:

47490 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation

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Cholecystogram: Radiological technique that providers use to produce radiologic images of the gallbladder.

Cholecystostomy: Creating an opening in the gallbladder.

Percutaneous: Through the skin; percutaneous procedures employ small skin incisions through which tubes and instruments can be inserted.

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​Coding short description​

  1. Use imaging guidance to place a needle in the gallbladder.

  2. He advances a guide wire through the needle and removes the needle.

  3. The provider then advances a catheter into the gallbladder via the guide wire and may take a small amount of bile to send to pathology for further analysis.

  4. He may administer injections of contrast dye in the gallbladder to perform a cholecystogram. The provider places a catheter in the gallbladder to drain the fluid.

CPT 65820 : Correct Coding​​

CPT  Code description:

65820 Goniotomy

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Goniotomy: Goniotomy is a type of eye surgery primarily used to treat congenital glaucoma, a rare condition that occurs in infants and young children. The procedure involves making an incision in the trabecular meshwork of the eye to improve the drainage of aqueous humor (the fluid in the eye) and lower intraocular pressure (IOP). This helps prevent damage to the optic nerve and preserves vision.

Gonioknife: Surgical knife which on incision helps to release intraocular pressure

Limbus: Boundary between the cornea and sclera.

Trabecular Meshwork: The trabecular meshwork is a key structure in the eye's drainage system, located in the anterior chamber between the cornea and the iris. Its primary function is to regulate the outflow of aqueous humor, the clear fluid produced in the eye, which helps maintain intraocular pressure (IOP)

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​Coding short description​

  1. When the patient is appropriately prepped and anesthetized, the provider incises the limbus and enters the anterior chamber using a gonioknife.

  2. He then opens the trabecular meshwork, the tissue of mesh located where the iris meets the sclera, to drain the aqueous humor. 

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CPT 66174 : Correct Coding​​

CPT  Code description:

66174 Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent

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Schlemm's Canal is a circular drainage canal located at the junction of the cornea and the sclera (the white part of the eye). It plays a key role in the natural drainage of aqueous humor.

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Canaloplasty is a minimally invasive glaucoma surgery that enhances the natural drainage system of the eye by widening Schlemm's canal to improve the outflow of aqueous humor.

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Subconjunctival: Just beneath the conjunctiva, the thin, moist membrane that lines the inner surface of the eyelids (palpebral conjunctiva) and the white part (sclera) of the eyeball (bulbar conjunctiva).

 

Trabecular Meshwork: The trabecular meshwork is a key structure in the eye's drainage system, located in the anterior chamber between the cornea and the iris. Its primary function is to regulate the outflow of aqueous humor, the clear fluid produced in the eye, which helps maintain intraocular pressure (IOP)

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​Coding short description​

  1. A subconjunctival incision (below the thin moist membrane covering the eye) and exposes the sclera (the white of the eye).

  2. The provider creates a scleral flap to access Schlemm’s canal, the natural drainage system of the eye.

  3. The provider expands this aqueous outflow canal to help relieve pressure in the eye. The provider may use different procedures. For instance, canaloplasty uses a microcatheter to place a suture around the full circle of the canal, pulling the suture to cinch the innermost part of the canal inward, thus opening the entire length of the ringlike canal.

  4. Another possibility is that the provider will inject a solution, such as a gel, to enlarge a portion of the canal. To complete the procedure, the provider closes the flaps without leaving a device or stent in place.

CPT 66170 : Correct Coding​​

CPT  Code description:

66170 Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery

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Ab externo: The outside of the eye; indication that surgery starts from the eye's exterior and proceeds to the anterior chamber.

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​Scleral fistulization: The surgical creation of a communication between two structures which were not previously connected.

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​Trabeculectomy: A surgical procedure that removes part of the trabecular meshwork in the eye to relieve pressure​​

​Coding short description​

  1. The provider creates a fistula through the scleral flap between the anterior chamber of the eye and the subconjunctival space.

  2. The provider removes part of the trabecular meshwork, increasing flow and drainage.

CPT 67036 : Correct Coding​​

CPT  Code description:

67036 Vitrectomy, mechanical, pars plana approach

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Vitrectomy: Surgical removal of vitreous humor.

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Phacofragmentation, or phacoemulsification: A technique in which the provider uses an ultrasonic device to fragment the cloudy lens, or cataract, to improve the vision.

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Pars plana: The darkly pigmented posterior area of the ciliary body, the structure that lies just behind the iris, and produces the aqueous fluid for the eye.​​

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​Coding short description​

  1. The vitreous humor is the semi liquid substance that fills the region between the lens and the retina of the eye. In this procedure, the provider removes this substance to gain surgical access to the back of the eye.

  2. When the patient is appropriately prepped and anesthetized, the provider places a special contact lens on the patient’s cornea, the transparent membrane of the outer layer of eyeball.

  3. The provider may use different types of vitrectomy equipment to incise the eye to expose the sclera and make incisions about the entire circumference of the cornea.

  4. Regardless of the equipment, the provider makes three small incisions to insert a lighted cannula, an infusion cannula, and cutting and suction instruments. Once the instruments are in place, the provider removes the vitreous from the eye, often referred to as a posterior sclerotomy.

  5. Finally, he removes the instrumentation and closes the incision in layers using sutures. He may inject a sterile solution into the eye to restore pressure. He may also apply a pressure patch with an antibiotic ointment.

CPT 58571, 38570 : Correct Coding​​

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