I have a provider stating the coding on a report was done incorrectly. I am hoping someone can help:
for this case it was coded as 67340, 67345, 67311 and J0585x5units for the botox
PREOPERATIVE DIAGNOSIS: Left esotropia with left face turn.
*
POSTOPERATIVE DIAGNOSIS: Left esotropia with left face turn.
*
PROCEDURE PERFORMED:
1. Left medial rectus recession, 6.0 mm.
2. Botox injection of left medial rectus 5 units.
*
ANESTHESIA: General.
*
COMPLICATIONS: None.
*
INDICATION FOR SURGERY: A 2-year-old with abduction deficit, left eye and left
esotropia. She had a prominent left face turn. The risks, benefits, and
alternatives of eye muscle surgery were discussed in detail with the patient’s
family. Informed consent was obtained.
*
In the operating room, general anesthesia was induced. Both eyes were prepped
and draped in sterile fashion in preparation for surgery. Forced duction testing
was performed. Interestingly, there was no restriction in the left eye (as might
have been expected for a possible Duane syndrome). Adhesive tape was applied
over the right eye. A lid speculum was placed in the left eye. A corneal
protective shield was placed. The 6-0 silk traction sutures were placed at 12
o’clock and 6 o’clock, then a conjunctival peritomy was performed nasally.
Marking sutures were placed at the edges of the wound. Radial incisions were
made superior and inferior. Blunt dissection was carried out to the sclera was
visualized. The medial rectus muscle was hooked in its entirety and cleaned of
the surrounding tissue. The insertion was measured at 5.5 mm from the limbus.
An Apt clamp was placed posterior to the insertion. The muscle was cut from the
insertion. A double-armed 6-0 Vicryl suture was woven through the belly of the
muscle and locked at each end. The Apt clamp was released. The muscle was
recessed 6.0 mm with direct attachment to the sclera. Inspection revealed the
muscle to be secured in the proper position. After the muscle was securely in
position, a retractor was placed into the wound and 5 units of Botox were
injected directly into the muscle belly of the medial rectus muscle. A Weck-Cel
sponge was placed immediately on each side of the muscle to absorb any spillover.
The conjunctiva was then closed at the limbus using interrupted 8-0 Vicryl
suture. Subconjunctival Ancef and dexamethasone were administered. Maxitrol
drops and lidocaine jelly were placed. The patient tolerated the procedure well.
She was awakened from general anesthesia and brought to the recovery room in
stable condition.
*
Sincerely,
MD
for this case it was coded as 67340, 67345, 67311 and J0585x5units for the botox
PREOPERATIVE DIAGNOSIS: Left esotropia with left face turn.
*
POSTOPERATIVE DIAGNOSIS: Left esotropia with left face turn.
*
PROCEDURE PERFORMED:
1. Left medial rectus recession, 6.0 mm.
2. Botox injection of left medial rectus 5 units.
*
ANESTHESIA: General.
*
COMPLICATIONS: None.
*
INDICATION FOR SURGERY: A 2-year-old with abduction deficit, left eye and left
esotropia. She had a prominent left face turn. The risks, benefits, and
alternatives of eye muscle surgery were discussed in detail with the patient’s
family. Informed consent was obtained.
*
In the operating room, general anesthesia was induced. Both eyes were prepped
and draped in sterile fashion in preparation for surgery. Forced duction testing
was performed. Interestingly, there was no restriction in the left eye (as might
have been expected for a possible Duane syndrome). Adhesive tape was applied
over the right eye. A lid speculum was placed in the left eye. A corneal
protective shield was placed. The 6-0 silk traction sutures were placed at 12
o’clock and 6 o’clock, then a conjunctival peritomy was performed nasally.
Marking sutures were placed at the edges of the wound. Radial incisions were
made superior and inferior. Blunt dissection was carried out to the sclera was
visualized. The medial rectus muscle was hooked in its entirety and cleaned of
the surrounding tissue. The insertion was measured at 5.5 mm from the limbus.
An Apt clamp was placed posterior to the insertion. The muscle was cut from the
insertion. A double-armed 6-0 Vicryl suture was woven through the belly of the
muscle and locked at each end. The Apt clamp was released. The muscle was
recessed 6.0 mm with direct attachment to the sclera. Inspection revealed the
muscle to be secured in the proper position. After the muscle was securely in
position, a retractor was placed into the wound and 5 units of Botox were
injected directly into the muscle belly of the medial rectus muscle. A Weck-Cel
sponge was placed immediately on each side of the muscle to absorb any spillover.
The conjunctiva was then closed at the limbus using interrupted 8-0 Vicryl
suture. Subconjunctival Ancef and dexamethasone were administered. Maxitrol
drops and lidocaine jelly were placed. The patient tolerated the procedure well.
She was awakened from general anesthesia and brought to the recovery room in
stable condition.
*
Sincerely,
MD
thoughts? should it be 67311, 67345 and the J0585 only?