From the health record of a patient with cataracts treated in outpatient surgery at the eye center: Operative Report Procedure: Extracapsular cataract extraction with intraocular lens implantation, left eye Diagnosis
5.76. From the health record of a patient with cataracts treated in outpatient surgery at the eye center: Operative Report Procedure: Extracapsular cataract extraction with intraocular lens implantation, left eye Diagnosis: Bilateral nuclear sclerotic cataracts Technique: The patient was given a retrobulbar injection of 2.5 to 3.0 cc of a mixture of equal parts of 2 percent lidocaine with epinephrine and 0.75 percent Marcaine with Wydase. The area about the left eye was infiltrated with an additional 6 to 7 cc of this mixture in a modified Van Lint technique. A self-maintaining pressure device was applied to the eye, and a short time later, the patient was taken to the OR. The patient was properly positioned on the operating table, and the area around the left eye was prepped and draped in the usual fashion. A self-retaining eyelid speculum was positioned and 4-0 silk suture passed through the tendon of the superior rectus
Case Studies from Ambulatory Health Records muscle, thereby deviating the eye inferiorly. A 160 fornix-based conjunctival flap was created, followed by a 150 corneoscleral groove with a #64 Beaver blade. Hemostasis was maintained throughout with gentle cautery. A 6-0 silk suture was introduced to cross this groove at the 12 o’clock position and looped out of the operative field. The anterior chamber was then entered superiorly temporally, and after injecting Occuconn, an anterior capsulotomy was performed without difficulty. The nucleus was easily brought forward into the anterior chamber. The corneoscleral section was opened with scissors to the left and the nucleus delivered with irrigation and gentle lens loop manipulation. Interrupted 10-0 nylon sutures were placed at both the nasal and lateral extent of the incision. A manual irrigating-aspirating setup then was used to remove remaining cortical material from both the anterior and posterior chambers. At this point, a modified C-loop posterior chamber lens was removed from its package and irrigated and inspected. It then was positioned into the inferior capsular bag without difficulty, and the superior haptic was placed behind the iris at the 12 o’clock location. The lens was rotated to a horizontal orientation in an attempt to better enhance capsular fixation. Miochol was used to constrict the pupil, and a peripheral iridectomy was performed in the superior nasal quadrant. In addition, three or four interrupted 10-0 nylon sutures were used to close the corneal scleral section. The silk sutures were removed, and the conjunctiva was advanced back into its normal location and secured with cautery burns at the 3 o’clock and 9 o’clock positions. Approximately 20 to 30 mg of both gentamicin and Kenalog were injected into the inferior cul-de-sac in a subconjunctival and sub-Tenon fashion. After instillation of 2 percent pilocarpine and Maxitrol ophthalmic solution, the eyelid speculum was removed and the eye dressed in a sterile fashion. The patient was discharged to the recovery room in good condition. Assign the correct codes and modifier for this encounter. ICD-10-CM and CPT Code(s):
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