MEDICAL BILLING AND CODING
Eye, Ocular Adnexa, Auditory, and Operating Microscope
CHAPTER 22
http://www.tedmontgomery.com/the_eye/
http://kidshealth.org/kid/health_problems/index.html
http://eyecanlearn.com/index.htm#Pursuits:
Can use RT, LT, or -50 to indicate which eye (s) a procedure was performed on.
Watch for surgeries that state “1 or more sessions”. This means that if the laser surgery is performed on
the same eye more than once in the 90 day post op period, you cannot bill the laser again. If on a
different eye, you can bill in the post op period by adding modifier -79. This statement is applicable to
the laser surgeries. These types of surgeries have a 90 day post op period.
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Eye, Ocular Adnexa, Auditory, and Operating Microscope
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http://www.allaboutvision.com/
Ever what it is that eye doctors do for your annual eye exam every year?
You are roomed by the technician who will perform the following tests before the eye doctor sees you.
o Visual Acuity (VA) – a test to see how well you can see (are you 20/20?)
 The reason that the number “20” is used is because the standard length of an eye
exam room is about 20 feet. (This is the distance from the patient to the eye chart)
o
o
o
Intraocular Pressure (aka Tonometry) – a measurement of the fluid pressure in your eye.
Controntational Visual Field (VF) – when the technician asks you to cover one eye and asks you
to look straight ahead while they move their finger up and down and sideways. The technician is
trying to see if you have visual field loss. (ex. You are driving in your car and you notice a car
coming up along side of you so you move your vehicle over one lane. If you have visual field
loss, you do not see the car that comes up along side of you and whoops, you swerve to avoid
that vehicle and may end up in an accident).
Extraocular Movement (EOM) - You are asked to sit or stand with your head erect and a forward
gaze. The technician will hold a pen or other object 12 inches in front of your face. He or she will
then move the object in several directions and ask you to follow it with your eyes, without moving
your head.
.
Parts of the eye that are examined by the doctor
Adnexa (e.g. Eyelids)
Conjunctiva
Cornea
Anterior Chamber (A/C)
Lens
Pupils/Iris
Optic Nerve
Vessels / Retina / Macula
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Eye and Ocular Adnexa (65091 – 68899) – Code ranges taken from the Ingenix Coding Companion
1. Eyeball (65091 – 65286)
o Removal of Eye – done because of eye disease or trauma
 Evisceration – removal of the contents of the globe while leaving the extraocular
muscles and sclera intact (65091, 65093)
 Enucleation – removal of the eye while leaving the orbital structures intact (6510165105)
 Exenteration – removal of the eye, Adnexa, and part o the bony orbit (6511065114)
 When putting in a fake eye aka eye prosthesis aka ocular implant aka artificial eye
– diagnosis is V43.0 or V52.2
 Repair of Lacerations – Eyes can use codes in the 65720-66220 or laceration
repair codes in the 11000 section of CPT. Need to know the location of the
laceration and how deep the laceration runs for code selection.
o (See coding scenario 1 below)
o (See coding scenario 2 below)
 Note: The type of eye doctor performs a ruptured globe surgery is known as an
Oculoplastic Ophthalmologist
2. Anterior Segment (65400 – 66990)
o Code Range 66982-66986
 Note: The type of eye doctor who normally does these types of surgeries
specialize in cataract surgery/anterior segment
o Code range 65850-65855
 Note: The type of eye doctor who normally does these types of surgeries is called
a glaucoma specialist
o Code: 66821 – Yag Capsulotomy – type of laser surgery performed after cataract surgery
 Linking diagnosis range (366.50 – 366.53)
 If performed within 90 day global period of cataract surgery – use 78 modifier with
RT or LT (because it is considered to be related surgery to cataract surgery)
3. Posterior Segment (67005 – 67255)
 Note: The type of eye doctor that does these types of procedures is called a retina
specialist
o Ocular Adnexa (67311 – 67975) (see coding scenario 3 below)
 Broken down by 67311 – 67332
 Known as Strabismus surgery
 Mostly performed on children
 This type of eye doctor is called a Pediatric Ophthalmologist
 Diagnosis are in the 378.xx range
 67820 – insertion of punctual plugs (see coding scenario 4 below)
 Eyes can use 2 sets of lesion removal codes (67800 – 67850)
 Excision, Destruction – codes for removal of lesion include more
than skin (i.e. involving lid margin, tarsus, and/or palpebral
conjunctiva.
 Integumentary codes – Skin only
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Eye, Ocular Adnexa, Auditory, and Operating Microscope
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Code range 67900 – 67924
 The type of eye doctor that does these types of procedure is
called an Oculoplastic Ophthalmologist
 67412 – Surgery for Dermoid Cysts (see coding scenario 5 below)
 Type of doctors who normally perform this type of procedure
can be a pediatric ophthalmologist, neuron-ophthalmologist, or
an oculo-plastic ophthalmologist
o Oculoplastic Ophthalmologist performs these types of procedures
 67971 – Reconstruction of eyelid, full thickness by transfer of
tarsoconjunctival flap from opposing eyelid: up to two-thirds of eyelid, one
stage or first stage
 67973 – Total eyelid, lower, one stage or first stage (Hughes Procedure I)
 67974 – total eyelid, upper, one stage or first stage (Hughes Procedure I)
 67975 – second stage (Hughes Procedure II)
 Note: The term Hughes Procedure I and II are not stated in the
CPT book. Need to add.

4. Conjunctiva (68020 – 68850)
o Incisions
o Excisions
o Conjunctoplasty
o Repairs
o Flaps
o 68400 – 68550 – minor/major surgical procedures that deal with your tear ducts
 Dacryocystotomy or dacryocystostomy (aka DCR)

Neuro-ophthalmologists specialize in visual problems deriving from issues related to the brain
not the eyes. Neuro-ophthalmology is a subspecialty of both neurology and ophthalmology, requiring
knowledge in problems of the eye, brain, nerves and muscles
Some types of eye diseases that these doctors treat are pituitary tumors, migraines, graves
ophthalmology, Bell’s Palsy, Intracranial Tumors, nerve palsy, optic neuritis, etc.
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MEDICAL BILLING AND CODING
Eye, Ocular Adnexa, Auditory, and Operating Microscope
CHAPTER 22 Coding Scenario’s
(Coding Scenario 1)
65280-LT and 871.4, 930.0
Preoperative Diagnosis: Corneal foreign body with perforation, left eye. Foreign body is metallic iron.
Postoperative Diagnosis: Same
Operation: Removal of corneal metallic foreign body, toilet of wound and suture of cornea, left eye
Description of Procedure: The patient was brought to the operating room after informed consent
outlining the risks, benefits, alternatives and complications of the procedure.
He received an O’Brien and peribulbar block employing a 50-50 mixture of 0.75% Marcaine and 2%
Xylocaine with Wydase added. He was prepped and draped in the usual manner, avoiding any undue
pressure on the eye.
In the operating room, a speculum was placed between the lids of the left eye, and since location of the
foreign body injury was at approximately 12:30, a superior rectus bridle suture was placed under the
belly of the superior rectus muscle with 4-0 silk suture material. The entry wound in the cornea was a
flap tear, with the foreign body lodged in the cornea and tearing Descement’s membrane, so there was a
positive Seidel. It was felt that the best approach would be to come from behind to push this outward.
Therefore, a paracentesis was made at approximately 12 o’clock with a Supersharp blade, and
Viscoelastic was injected posterior to the injury site. Using the cannula to a press externally and opening
the wound, I was able to dial the foreign body from its location. There was a small amount of micro
debris, which was also irrigated free. To further toilet the wound, I injected viscoelastic in the anterior
chamber at the wound site, followed by the balanced salt solution. This was done 3 times, after which
the wound appeared entirely clear.
Two 10-0 nylon sutures were placed across this wound, which was quite irregular in configuration. For
safety, a 10-0 nylon suture was also placed through the paracentesis wound. The patient received
Zymar x4 preoperatively and intraoperatively after suture placement and scopolamine x 2. The bridle
suture and speculum were removed. Macular shield was used throughout when possible. This was
removed. Polysporin ointment was instilled, and the eye was patched with a patch and a shield. The
wound was cultured, and the foreign body was cultured. Note that the foreign body appeared to be rust
metal, which measured 1 x 0.6mm, and it was somewhat trapezoidal in shape. The patient tolerated the
procedure well.
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(Coding Scenario 2)
Coding: 65272-LT, Diagnosis: 802.6
PREOPERATIVE DIAGNOSIS: Ruptured globe, left eye
POSTOPERATIVE DIAGNOSIS: Ruptured globe, left eye.
NAME OF OPERATION: Repair of left ruptured globe.
ESTIMATED BLOOD LOSS: Less than 1 mL.
IMPLANTED DEVICES: Tutogen Tutoplast allograft "preserved pericardium."
(Tutoplast comes from a cadavor)
DESCRIPTION OF PROCEDURE: The patient presented to the ER by ambulance earlier last night after
he was accidentally stabbed in the left eye by a metal work working instrument while in a wood shop.
After diagnosis of ruptured globe was made both clinically and on CT scan risks, benefits and
alternatives of repairing the globe were discussed. After consent was obtained, the patient was brought
to the operating room where a time-out was taken to identify the patient, operation and site of operation.
He was then given general anesthesia and prepped and draped in the usual sterile ophthalmic fashion
being careful to put no minimal pressure on the left globe while prepping. The lid speculum was then
placed and using the operating microscope the eye was further explored. There was obvious shelved
vertical corneal laceration vertically almost completely from the inferior cornea up to the superior cornea
and extending into the sclera. There was strands of *** and uveal tissue as well as some vitreous which
were amputated and cut with a Westcott as they were not viable. Complete 360 degree peritomy was
then performed to provide further exposure and further evaluate the injury. The corneal scleral laceration
extended from the 10 o'clock on the cornea to the superior nasal sclera running very far back just parallel
and superior to the superior edge of the medial rectus muscle. After full extent of the injury had been
identified 10-0 nylon sutures were used to close the corneal laceration starting at the limbus as meeting
point. The scleral laceration portion was then closed with multiple interrupted sutures using 9-0 nylon
suture. After the entire laceration had been sutured multiple stitches were removed and replaced with
ones that then fit better. The corneal sutures were then rotated and buried into the cornea. A
paracentesis port was made using super sharp blade and balanced salt solution was irrigated into the
anterior chamber to wash out the hyphema as well as to test the closure. The anterior chamber did form
and hold pressure at this point. Due to inability to rotate the scleral sutures well, Tutoplast was placed
over them to protect them from rubbing on the conjunctiva. The Tutoplast was sutured into position with 2
interrupted 7-0 Vicryl sutures at the inferior border. The conjunctiva was then also closed using the 7-0
Vicryl. At the end of the case subconjunctival dexamethasone and cephazolin were injected under the
conjunctiva by using a cannula. The eyelid speculum was then removed and TobraDex ointment was
placed in the eye. A patch followed by a shield were then placed over the eye as well. The patient
returned to the recovery room in good condition.
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(Coding Scenario 3)
Superior and inferior oblique muscles vertical
67318 – any procedure superior oblique muscle
Medial and lateral rectus muscles have only horizontal actions
67311 – 1 horizontal muscle
67312 – 2 horizontal muscles
Superior and inferior rectus muscles are the primary vertical movers of the eye.
67314 – 1 vertical muscle (excluding the superior oblique)
67316 – 2 or more vertical muscles (excluding the superior oblique)
Preoperative and Postoperative Diagnosis: Strabismus, Bilateral
Procedure: Medial Rectus Recession Bilateral (67311-50)
Indications: Young patient with congenital esotropia (378.05 – Infantile Strabismus)
After informed consent obtained, patient was taken to the operating room and underwent general
anesthesia. The right eye was prepped and draped in the usual sterile, ophthalmic fashion. A Lancaster
lid speculum was placed. Two mersilene anchor sutures were placed at the superior and inferior limbus
to abduct the right eye. Gel foam gauze was used to protect the cornea. A limbal based conjunctival
incision was made with Wescott scissors, and a conjunctival flap was created over the medial rectus.
The medial rectus insertion was exposed. The medial rectus was hooked with a Stevens hook and then
passed onto a green muscle hook. The muscle was freed from its attachments with Wescotts. A 6-0
double armed vicryl safety stitch was placed centrally, then a locking stitch was then placed at the MR
insertion on either side. A Wescott scissors was used to then cut the muscle. Bipolar cautery was used
to achieve hemostasis. A caliper was used to measure 10.5 mm posterior to the limbus (for a 5.5 mm
recession). The muscle was then sewn to the sclera at this point using 6-0 vicryl. The remaining muscle
was cut off the insertion and the specimen discarded. Tenons was closed with a Single 8-0 vicryl suture
and the conjunctiva was then closed with 8-0 vicryl suture. The same procedure was then carried out on
the left eye without complications.
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Eye, Ocular Adnexa, Auditory, and Operating Microscope
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(Coding Scenario 4)
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(Coding Scenario 5)
67412 – Procedure for Dermoid Cysts, Diagnosis: 224.7
Procedure requires going all the way down to the bone and then tracks back to the bone. During
development, skin tissue gets caught between the skull bones. The skin tissue keeps growing. It’s a
waxy, keratin, cheesy type of substance in the dermoid cyst itself.
Preoperative and Post Operative Diagnosis: Right superotemporal orbital mass
Procedure: Anterior orbitotomy and excisional biopsy of lacrimal gland mass
Indications: Patient with a history of a right orbital mass. The risks, benefits, and alternatives
associated with right anterior orbitotomy and excisional biopsy were discussed with the patient
preoperatively. The patient wished to proceed with the surgery after signing the informed consent form.
Description of Procedure: The patient’s eyelid crease was marked with a marking pen. The borders of
the mass were also demarcated. Local anesthesia consisting of 2% Lidocaine with a 1:100,000 dilution
of epinephrine and 5% Marcaine with epinephrine was injected into right upper eyelid. A total volume of
4cc was administered. The patient was then prepped and draped in the usual sterile fashion for
ophthalmic surgery.
A #15 blade was used to make incision over the previously marked line. Bipolar was used as necessary
to maintain adequate hemostasis at this portion as well as throughout the remainder of the procedure. A
pair of Westcott scissors and forceps were used to dissect through until the mass was visible. The
lacrimal gland mass was carefully dissected with blunt and sharp dissection from neighboring structures.
The appearance of the tumor was consistent with a pleomorphic adenoma. The tumor was dissected
from normal looking lacrimal gland. Posteriorly the resection was extended to avoid rupture of the
pseudocapsule. Hemostasis was obtained with bipolar cautery. Once the specimen was resected
entirely without rupturing the pseudocapsule, it was sent to pathology in formalin. A 6-0 prolene suture
was then used to approximate the remaining lacrimal gland tissue to the orbital rim to prevent prolapse.
The skin incision was closed with 6-0 prolene deep sutures to approximate the skin borders. The skin
was then closed with a 6-0 prolene running suture.
The patient was then cleansed with wet-to-dry gauze dressings. Ophthalmic antibiotic ointment was
placed along the patient’s incision line. Iced compresses were immediately placed over the eye. The
patient tolerated the procedure well and was taken to the recovery room in excellent condition.
Final Pathologic Diagnosis - Lacrimal gland mass, side not specified, excision -- Pleomorphic
adenoma
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MEDICAL BILLING AND CODING
Eye, Ocular Adnexa, Auditory, and Operating Microscope
CHAPTER 22
http://www.ghorayeb.com/EarAnatomyDiagram.html
Simplified Anatomy of the Ear.
About your ears
http://kidshealth.org/kid/htbw/htbw_main_page.html
http://www.surgery.com/videos/stapedectomy-surgery-video
Auditory System (69000 – 69979)
o
o
o
External Ear
 Earwax removal (69200, 69205), pg 653 SBS TB
Middle Ear
 Surgery for ear tubes (69433, 69436), pg 653-654 SBS TB
 Myringotomy – incision into the tympanic membraine and reinflation of the eustachian
tube
 Tympanostomy – insertion of a small plastic or metal tube
 http://www.surgery.com/procedure/myringotomy-and-ear-tubes
Inner Ear
 Cochlear Device Implant (69930), pg 655 SBS TB
o New and upcoming procedure for people who had hearing and then lost their
hearing
http://www.surgery.com/videos/cochlear-implants-surgery-video
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o
Temporal Bone, Middle Fossa Approach (69950, 69955, 69960, 69970), pg 656 SBS TB
 Example: Treatment for tumors such as “Acoustic Neuroma: - An acoustic neuroma is
a benign tumor that develops on the eighth cranial nerve, which carries sound and
balancing information from your inner ear to your brain. The pressure on the nerve
may cause hearing loss and dizziness.
http://www.mayoclinic.org/acoustic-neuroma/?mc_id=comlinkpilot&placement=bottom
Coding Scenario
CPT – 69436-50 (surgery performed on left and right ears), diagnosis - 382.9 (unspecified chronic otitits
media)
Preoperative and Postoperative Diagnosis: Recurrent otitis media
Procedure: Bilateral myringotomy and PE tubes
Indications for Surgery: Patient with longstanding ear infections that have been affecting his hearing. He
has had chronic fluid and acute infections. In addition to this, he has quite severe snoring and large
tonsils, with a history for obstructive sleep apnea.
Procedure: After informed consent was obtained, he was brought to the operating room and general
endotracheal anesthesia was established. First, the ears were examined. There was no acute infection
under the microscope, but there were some cerumen (ear wax) in the ear canals. This was removed on
both sides. The left ear was examined first. A posterior-inferior radial myringotomy was performed and a
PE tube was trans-tympanically placed. There was a lot of thick mucoid fluid on that side, but no acute
infection. Ciprodex drops were then placed. Next, an identical procedure was carried out on the right
side. The ear was clean. Speculum was placed. A posterior-inferior myringotomy was performed with a
myringotomy blade and a PE tube was trans-tympanically placed. Drops were placed on the right side
as well. This was all done under the standard operating size microscope.
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