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Review the case and indicate the correct code(s). Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. Case 2 Date of Surgery: 10/3/XXXX Preoperative Diagnosis: NUCLEAR CATARACT OD Postoperative Diagnosis: Same as above. Procedure: Cataract Removal Lens Implant OD Anesthesia: Topical Surgeon: Samantha Friends In the preoperative area, the anesthesia department applied a topical anesthesia of 2% Xylocaine gel to the patient’s right eye. In the operating room, the patient’s right eye was prepared and draped in the usual manner. A Barraquer wire speculum was placed between the lids. Ocucoat was applied to the cornea. A side port incision was made at 12 o’clock. Healon 5 was instilled into the anterior part of the anterior chamber. A bent needle with balanced salt solution was then placed into the anterior chamber and used to deepen the anterior chamber between the lens and the Healon 5, and was used to produce a continuous circular capsulorhexis. A 1.1 mm diamond incision was made at the limbus about 2 mm long temporally. The side port incision was then superiorly increased to 1.1 mm. Hydrodissection of the nucleus was done with a Ryecroft cannula on a syringe containing l/3 cc of unpreserved 1% Xylocaine, after clearing a path to the incision. After the fluid wave was completed, the lens was rotated 180 degrees and flipped within the capsular bag. Healon 5 was then placed between the lens and the cornea, the cornea incision made temporally and superiorly. An irrigating Bechert nucleus rotator was placed through the superior incision, and the Phaco tip was placed through the temporal incision. The lens was emulsified within the capsular bag. An irrigating hand piece with an irrigating solution containing epinephrine, Vancomycin, and Gentamycin was then placed through the superior incision and an aspiration hand piece through the temporal incision. This was used to remove the cortical remnants and polish the capsule. Healon 5 was then placed into the anterior chamber to plug up the capsulorhexis. Balanced salt solution was then placed below this into the capsular bag to deepen the capsular bag. A 2.8 mm diamond keratome was used to enlarge the 1.1 mm temporal corneal limbal incision. A 17.0 diopter AMO lens was carefully inspected, irrigated, and loaded into the unfolder and placed through the incision and the leading haptic, placed into the capsular bag followed by the optic and then the trailing haptic. The irrigation aspiration hand pieces were then used to remove the viscoelastic. The lens was carefully inspected and was in good position. The incisions were hydrated with balanced salt solution. The anterior chamber was restored to its normal depth with irrigating solution. The incision was checked for leakage. The conjunctiva and cornea were flushed with a Betadine solution. The speculum was removed. Blood loss was minimal. The patient left the operating room in good condition. There were no complications of surgery. ICD-10-CM Code: CPT Code:

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