CPC Chapter 15

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Chapter 15 Eye and Ocular Adnexa, Auditory Systems Introduction The eyes and ears are parts of the nervous system, but both CPT* and ICD-10-CM treat them separately from the rest of the nervous system codes. This is because the eyes and the auditory system are very specialized, anatomically, and as sense organs, vital to our overall well-being that warrant separate consideration. Coding disorders and procedures for the eyes and ears requires an understanding of the interdependencies of sight and sound components. We will look at how these structures work together to serve our senses and review the various surgeries that restore sight and hearing damaged by disease. Objectives » Understand the anatomic structure and function of the eye and ear o Define key terms ¢ Understand the most common pathologies affecting these sense organs » Understand eye surgeries and ear surgeries and how they relate to pathologies * Recognize common eponyms and acronyms for these specialties * Identify when other sections of CPT® or ICD-10-CM should be accessed o Know when HCPCS Level Il codes or modifiers are appropriate Anatomy and Medical Terminology The eye and ear are both complex organs that have unique structures and nomenclature. The most important concept to understand regarding the eye is refraction. The ear has two key functions: conduction and balance. The Eye Vision is all about light. Light enters the eye; sensors read the image and transmit information to the brain. On its way to those sensors, the light travels through several transparent layers of the eye. These layers are responsible for refraction of the light. In refraction, the eye bends and focuses light rays into a sharp image. If the light is refracted imperfectly, vision blurs. People who wear glasses or contacts are adding a corrective layer of refraction to their eyes to improve their sight. Surgery can be performed to correct the error in refraction. The eyeball is just that, a ball. It is composed of a tough membrane called sclera. The sclera is the outer coat of the globe and is continuous with the dura via the dural sheath of the optic nerve at the back of the eye. The sclera at the front of the eye is known as the white of the eye and is covered with a thin protective layer of conjunctiva. The sclera is tough so that the contents of the eye are protected, and so that the shape of the eye remains consistent. The middle layer of the eye is the choroid layer, a dark, unreflective layer, which contains a rich supply of blood. The inner layer is the retina, with light and color receptors, which send light data to the brain via the optic nerve. The shape of the eyeball affects refraction. If the eyeball is too oblong, the patient will be nearsighted (myopia), and refraction will cause blurring of far away objects. In farsightedness (hyperopia), the eyeball is foreshortened, and close up vision is impaired. 3 ™ Cbarybody . — - ) S 0 T ~—Z ~ A h vy Arcssior chamber B, 4 \ e T T o . 7 A \ - Postarse | s ritem - A NN \ wrh o s bt .\“ ——— — \ F Artmiy T s N, o . - b - - " Comes ~ 3 » . 24 ( g e = '_-'.“ " ) ) \ Q o a - . A% ;}x : 4 . The Eye G g , A ol Fluids within the eyeball help maintain its consistent shape. Any reduction in fluid within the eye will affect the shape of the eye, just like letting air out of a beach ball, and will affect refraction. Severe dehydration and numerous medical conditions can affect the shape of the eye and cause blurred vision. Each eye has six muscles that work in tandem to control movement of the eyeball up and down and from side to side as we focus on an object. If we follow the path of light in the eye, it first enters through the cornea, which is the bay window of the eye. The cornea has five layers that refract the light entering the eye. The layers from the surface of the cornea inward are: o Epithelium layer ¢ Bowman's layer (a tough basement membrane) ¢ Stroma (collagen fibers supporting keratocytes) ¢ Descemet’s layer (an inner basement membrane) ¢ Endothelium layer (crucial layer that keeps the cornea from getting too wet).
Chapter 15: Eye and Ocular Adnexa, Auditory Systems The layers are important because corneal defects are sometimes managed by removing one or two layers (lamellar keratoplasty), rather than full-thickness cornea (penetrating keratoplasty). This is done to preserve the fluid balance of the eye and prevent leaks through full-thickness incisions. The cornea meets the sclera in a ring called the limbus, also known as the sclerocorneal junction. Physicians often reference the limbus when describing the site of incision in eye surgery. Behind the cornea is the anterior segment of the eye, which is filled with a clear, salty fluid, called aqueous humor. The anterior segment is divided into the anterior chamber (back of cornea to the iris) and posterior chamber (back of iris to the lens) and it is filled with aqueous humor. The aqueous humor functions as another source for refraction and provides stability to the corneal walls. Light from the aqueous humor enters the crystalline lens, a convex disc suspended on threads just behind the iris. We know the iris as our source of eye color, but this colorful tissue is a muscle that expands and contracts to regulate the amount of light entering the posterior chamber of the eye through the pupil. If the light is too bright, the iris expands so that the size of the pupil shrinks. If there is too little light, the iris contracts to enlarge the pupil and allow more light into the eye. The threads (ciliary zonules) holding the lens and the ciliary body to which they are connected automatically tug at the lens to change its shape to help focus on items near or far. This refraction function gets slower and less effective with age, which explains why so many older adults find themselves getting prescriptions for reading glasses (presbyopia). After the light has been bent by the crystalline lens, it enters the vitreous humor, a gel-like mass that fills the large posterior segment of the eye. The vitreous humor presses against the inner layer of the eye, maintaining the eyeball’s shape and keeping the blood-rich choroid layer in contact with the retina. The light is placed upon the retina's rods and cones (photoreceptors) like a projected image at a movie theater, and these images are transmitted via the optic nerve to the brain. Rods located around the edges of the retina utilize low lighting and distinguish differences in shapes and distances, while cones utilize bright light conditions and distinguish color. The macula is an oval-shaped highly pigmented yellow spot near the center of the retina. Near its center is the fovea centralis, which contains the highest concentration of cone cells. To trace again the refraction path: Light travels from the cornea, through aqueous humor, to the lens, through vitreous humor, to the retina. The stability of the eyeball and the refractive elements must be perfect for vision to be 20/20. There is plenty to go wrong, which is why the eyeball is nestled in a bony socket lined in protective fat. A direct blow to the eye will often damage soft tissue around the bony orbit but not harm the eye itself. Further protecting the eye are eyelashes and eyebrows, which protect from foreign bodies as well as excess light, and the eyelids, which keep eyes from drying out. The lacrimal system produces tears in glands behind the eyebrows. These tears flow through ducts into the eyes where they drain out the lacrimal puncta, or flow into the nose (which explains why we blow our noses when we cry). The visual field can be affected by many things: blood, foreign bodies, or other tissue can obstruct the pathway to the retina. Examples include excessive skin on the eyelids, shielding a portion of the eye from light, a cloudy condition (for example, cataract) in any of the refractive properties of the eye, or damage to the retina. Sometimes a change in the visual field is the chief complaint when a patient schedules an appointment with the ophthalmologist. The Ear Conduction refers to the transfer of sound waves. Sound waves take two paths in humans. The waves can be captured by the pinna, or outer ear, and travel by air along the external auditory meatus to the tympanic membrane. True to its name, the tympanic membrane vibrates to telegraph its message to the middle ear, where the malleus picks up the vibration, and transfers it to the incus and stapes. These three tiny bones, the ossicles, carry the message to the oval window. As the stapes footplate moves the oval window and creates waves in the perilymph of the scala vestibuli of the cochlea, the round window membrane moves, which causes movement of the endolymph inside the cochlear duct. This causes the basilar membrane to vibrate, which in turn causes the organ of Corti (inner hair cells) to send electrical impulses along the auditory nerve to the brain. Secondary to this air conduction is bone conduction. The mastoid bones contain tiny air cells that also form a conductive path for sound. The mastoid cells transmit sound effectively, although not as efficiently as sound traveling from the pinna through the auditory canal. Loss of the mastoid function damages hearing, but more importantly, mastoid cell sensitivity can be augmented in patients who have experienced a hearing loss along the more traditional air conduction pathway. In either case, when the sound waves reach the auditory nerve, they are transmitted to the brain. The inner ear is responsible for balance in addition to the conduction of sound. Information within the vestibule and the three semicircular canals is sent to the brain, signaling the body to compensate by adjusting posture or movement as appropriate for the orientation of the body. Vertigo, or extreme dizziness, is often a symptom of inner ear disorders, such as Méniére’s disease. The entry to the ear is well protected by the meaty exterior, and the ear canal is lined with hairs and lubricated with cerumen to filter out foreign bodies. To equalize the pressure between the middle ear and outer world, the Eustachian tubes link the middle ear to the nasopharynx. Without this opening, the pressure of air in the middle ear would not change with the pressure outside, which would inhibit vibrations and hamper the ability to hear. It is the change in air pressure that causes ears to pop on airplanes or when changing altitudes. Without the Fustachian tubes, this would not be possible. Key Roots, Suffixes, and Prefixes for Eye and Ear Qacous, Ocus sound, hearing ot/o ear blephar/o eyeld phac/o lens canth/o corner of eyelid phot/o light cochle/o cochlea (inner ear) -ptosis drooping, downward displacement, prolapse conjunctiv/o conjunctival retin/o relina dacry/o tears, lacrimal sac or duct rhin/o nose dipl/o two scler/o hard, sclera (of eye) goni/o angle stapedi/o stapes ir/i, nt/o, ind/o ins tars/o margin of eyelid kerat/o comea trabecul/o relating to meshwaork for drainage of aqueous humor myring/o tympanic membrane uve/o uvea (of eye) -0opia condition of having a disease of eyels) vitre/o vitreous
Chapter 15: Eye and Ocular Adnexa, Auditory Systems Section Review 15.1 Using the CPT® code book to look up Strabismus in the index. Strabismus surgery would be performed to correct which of the following eye disorders? A. Removing a cloudy lens B. Balancing the strength of extraocular muscles C. Draining an orbital abscess D Reconstructing a damaged eyelid Answer: B. Balancing the strength of extraocular muscles Rationale: Strabismus in the CPT* Index takes you to code range 67311-67345. In the text, find the subheading entitled Extraocular Muscles. All of these codes involve the muscles moving the eyeball, and most of these codes address adjusting one or more ocular muscles to correct an imbalance in the muscles causing the eye to be pulled too much in one direction, causing disorders like crossed or wandering eyes. Which of the following has NO refractive properties? A. Cornea B C. Vitreous D Lens Iris Hide Answer « Answer: D. Iris Rationale: The iris is the colorful muscle contracting and expanding in a measured fashion, controlling the amount of light permitted into the posterior segment of the eye. While the iris is involved in rationing light, it does not have any effect on the bending of light. As an opaque body, the iris has no refractive qualities. Code 69210 in the CPT® code book describes removal of impacted earwax from the external auditory canal. What type of conduction is interrupted by impacted earwax? A B. C. n. Bone conduction Air conduction Bone and air conduction Neither bone nor air conduction Hide Answer » Answer: B. Air conduction Rationale: The hearing of a patient is interrupted by impacted ear wax, called cerumen. The wax interrupts air conduction of sound as it travels through the ear canal a cross the tympanic membrane to the middle and inner ear. Bone conduction is not affected by ear wax buildup. A. B C D The incus bone is between the malleus and the stapes. In which part of the ear is the incus located? The external ear The middle ear The inner ear The Eustachian tube Hide Answer Answer: B. The middle ear Rationale: The three ossicles (malleus, incus, and stapes) are found in the middle ear. When sound travels by air into the external auditory canal, it causes the tympanic membrane to vibrate. The sound is then transferred from the membrane to the tiny ossicles. From the stapes, the vibration is transferred to the oval window, which causes nerve to the brain. the round window to move and vibrate the endolymph of the cochlear duct. This causes the fine hairs in the organ of Corti to transmit impulses through the cochlear Which of the following statements is true regarding the vitreous humor? A. B. C D. It presses against the cornea so that the cornea keeps its shape. It signals the iris when to contract or expand. It produces tears that flow in the eyes and nose. It holds the retina firmly against the blood-rich choroid. Answer: D. It holds the retina firmly against the blood-rich choroid Rationale: Vitreous humor is a gel-like substance in the posterior segment. In addition to its refractive qualities, the vitreous is responsible for holding the shape of the eyeball and keeping the retina pressed against the blood-rich choroid in the posterior segment.
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems What is a blepharoplasty? Excision of tumor of the tear duct = Corrective surgery for refraction error C. Surgical repair of the eyelid D. Suture repair of the sclera Answer: C. Surgical repair of the eyelid. Rationale: Blephar/o is a root word identifying the eyelid, and plasty indicates a surgical repair. Keratoconus is a defect of which component of the eye? A. Cornea B. Lens C. Choroid D. Macula Answer: A. Comea Rationale: Kerat/o is a root word identifying the cornea. In keratoconus, the cornea protrudes, causing a refraction error. Its cause is unknown, but it is thought to be hereditary. What occurs in myringotomy? The external auditory canal is reconstructed. B. Myringa is removed from the inner ear. C. The tympanic membrane is excised. D. The tympanic membrane is incised. Answer: D. The tympanic membrane is incised. Rationale: Myring/o is a root word identifying the tympanic membrane and -otomy is a suffix indicating an incision. A patient has a disorder of the ear causing extreme vertigo. Which part of the ear is diseased? A. Theinner ear B. The middle ear C. The external ear D. None of the above Hide Answer » Answer: A. The inner ear Méniére’s disease and vestibular neuronitis. Rationale: The inner ear is responsible for balance in addition to conduction of sound. Vertigo, or extreme dizziness, is often a symptom of inner ear disorders including Based on what you have learned so far, which of the following statements is true? All components of the eyes and ears occur bilaterally. Most procedures for the eyes or ears are performed by specialists. The eyes and ears are the two most important sense organs in the body. All of the above. Answer: D. All of the above. Rationale: All of the above are correct. The eye and ear both occur bilaterally, and their individual components occur bilaterally as well. Even within ophthalmology, you will find specialists in one area. For example, retinal specialists work with diseases/conditions of the retina, and an ophthaimologist may specialize in cataract surgery. The same is true for otorhinolaryngology: within the specialty, you will find subspecialists for hearing and vestibular disturbances. Because they are organs of sight and hearing. communication, the eye and ear are considered to be the most important sense organs in the body. Physicians work very hard to safeguard and optimize their patients’
Chapter 15: Eye and Ocular Adnexa, Auditory Systems ICD-10-CM Most ICD-10-CM codes for the eyes and ears are found in Chapter 7, Diseases of the Eye and Adnexa (H00-H59) and Chapter 8, Diseases of the Ear and Mastoid Process (H60-H95). There are also a significant number of diagnosis codes for these organs found in other chapters of ICD-10-CM. It is imperative to begin your search for a code in the ICD-10-CM Alphabetic Index to ensure proper code assignment. An understanding of common disorders of these organs will help with code selection. The Eye Most disorders of the eye fall into these general categories: * Infection and inflammation » Neoplastic disease * Injury e (laucoma e (ataracts e Retinopathy * Retinal detachment e Strabismus Codes within the Diseases of the Eye and Adnexa chapter are organized according to anatomic site: Disorders of eyelid, lacrimal system and orbit (H00-H05); Disorders of conjunctiva (H10-H11); Disorders of sclera, cornea, iris, and ciliary body (H15-H22); Disorders of lens (H25-H28) including cataracts; Disorders of choroid and retina (H30-H36); Glaucoma (H40-H42); Disorders of vitreous body and globe (H43-H44); Disorders of optic nerve and visual pathways (146-H47); Disorders of ocular muscles, binocular movement, accommodation and refraction (H49-H52); Visual disturbances and blindness (1153-1154); Other disorders of eye and adnexa (H55-H57); Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified (H59). Infections and inflammation are listed in all categories based on the exact location of the infection or inflammation. Some eye infections are found in Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), such as herpes zoster (B02.3-) or herpes simplex (B00.5-), and trachoma (A71.-). Remember to report secondarily the infectious agent, if known (for example, B95.62 for MRSA). Most ICD-10-CM codes in chapter 7 require a 6™ character to identify which eye is affected by the condition being reported. This is the concept of laterality: right, left, bilateral, or unspecified. Neoplastic Disease—Codes for neoplasms of the eye are straightforward. Start in the ICD-10-CM Alphabetic Index with Neoplasm, neoplastic and you're directed to the Table of Neoplasms. Category C69 contains the malignancy codes of eye and adnexa. The 4™ character of the code identifies the location of the neoplasm. The 5™ character identifies laterality (right, left, unspecified). Ophthalmologists may note the patient has a dark spot on the retina. The retina is delicate and blood-rich, making it difficult to biopsy. Instead of a biopsy, the physician will monitor the spot for any change. This is sometimes called a retinal freckle. Report D49.81, for this condition, neoplasm of unspecified behavior of other unspecified sites. Melanoma of the eye is not reported from the Table of Neoplasms. In the Alphabetic Index look for Melanoma/in situ/eye, D03.8. Melanoma (malignant) C43.9 benign—see Nevus in situ D03.9 abdominal wall D03.59 ala nasi D03.39 ankle D03.7- malignant, of soft parts except skin—see Neoplasm, connective tissue, malignant In the Table of Neoplasms, look for Neoplasm, neoplastic/connective tissue NEC/Malignant Primary. Note that eye is not listed. There is an instructional note under connective tissue NEC indicating use for sites that do not appear in this list, code to site of neoplasm. Look for Neoplasm, neoplastic/eye NEC/Malignant Primary C69.9-. The Tabular List confirms the code to report is C69.90. Cataracts—Not only do the refractive elements of the eye need to be accurate in their ability to focus, they also need to be free of defects that could obscure vision. Cataracts describe flaws or clouds that develop in the crystalline lens and are reported with codes from categories H25-H28 depending on the type of cataract. These categories have separate codes for right, left and bilateral. Congenital cataract is coded with Q12.0. Cataracts occur naturally with age, but can occur secondary to trauma, foreign bodies, disease, or drugs. If a cataract impedes vision sufficiently, surgery can be performed to remove the crystalline lens, and an artificial intraocular lens (I0L) can be placed. The lens has many layers, and specific codes can be selected to identify cataracts by their layer. The outer layer is harder, like an M&M® candy’s outer shell. Often, when a cataract is removed from the eye, the physician opts to retain the posterior outermost shell so that there remains an organic separation between the posterior and anterior segments. Later, this remaining shell may develop opacities as well, and this is called an aftercataract or secondary cataract. Secondary cataracts are in subcategory H26.4-. Removal of an aftercataract is a fairly simple surgery. Retinopathy—Retinopathy describes changes that occur in the blood vessels within the retina. These aneurysms, hemorrhages, and proliferation of small vessels damage the retina and put the patient’s vision at risk. Retinopathy is most commonly seen as a complication of diabetes, but can also be caused by prematurity in newborns, by systemic hypertension, or other pathologies. The effect of diabetes on the eye is called diabetic retinopathy. In the earliest phase of the disease, called background or nonproliferative diabetic retinopathy, the arteries in the retina become weakened and leak, forming small, dot-like hemorrhages. These leaking vessels often lead to swelling or edema in the retina and decreased vision. The phases of nonproliferative retinopathy are mild, moderate, and severe.
Chapter 15: Eye and Ocular Adnexa, Auditory Systems e Diabetes Mellitus type 2 with proliférative retinopathy of the right eye The majority of diabetic codes with manifestations uses only one code to describe both. These are considered combination codes that include the condition with the manifestation or complication. Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic/type 2/with/retinopathy/proliferative E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Circulation problems cause areas of the retina to become oxygen deprived or ischemic. New, fragile vessels develop as the circulatory system attempts to maintain adequate oxygen levels within the retina. These vessels hemorrhage easily, and blood may leak into the vitreous and/or retina, causing spots or floaters and decreased vision. In the advanced phase of the disease, continued abnormal vessel growth and scar tissue may cause serious problems such as retinal detachment or glaucoma. Vessels damaged by retinopathy can be cauterized with a laser. Patients with retinopathy should be monitored regularly so any new disease is treated before permanent damage to vision occurs. Retinal Detachment—Injury or anatomic defect can cause the retina to be freed from the blood-rich choroid at the back of the eye. When the retinal layer floats away, it loses its supply of nutrients. Nutrients must return or vision is lost. Corrective action might include the injection of fluid, air, or external eye pressure to push the retina back into place, or bursts of laser to burn the retina to the choroid. Scleral buckling techniques are used in many patients. Vitrectomy occasionally is performed to gain access to the retina. At the end of surgery, gas or silicone oil is injected into the eye to replace the vitreous gel and restore normal pressure. Glaucoma—Too much pressure from fluid can lead to a hypertensive condition in the eye called glaucoma. When ocular pressure rises, pathological changes occur that can damage or destroy vision. The fluid in the front of the eye flows through an anatomical pathway. If this pathway is blocked, pressure against blood vessels can cut off bload to the eye, and blindness can follow quickly. Typically, the progression of disease is more insidious. In either case, the physician can perform surgery to revise the flow of aqueous in the eye and reduce the pressure. Glaucoma codes are covered in category H40 except for congenital glaucoma, which is found in category Q15. Many ICD-10-CM codes for glaucoma include the type and stage: * 0 stage unspecified * 1 mild stage * 2 moderate stage * 3 severe stage * 4indeterminate stage A 7® character is added to identify the stage of the glaucoma. Unspecified equates to not documented, while indeterminate stage equates to the physician being unable to determine the stage. A 7" character is added to identify the stage of the glaucoma. Unspecified equates to not documented, while indeterminate stage equates to the physician being unable to determine the stage. Laterality is also included in the choice of codes. ICD-10-CM guidelines 1.C.7.a 2 and 1.C.7.a.3 have specific rules for coding bilateral glaucoma with same or different types and stages. * When a patient has bilateral glaucoma and both eyes are documented as the same type and stage - and there is a code for bilateral glaucoma -a code is assigned for bilateral glaucoma with the appropriate 7 character for the stage. * When a patient has bilateral glaucoma and both eyes are the same type and stage - and the classification does not provide a code for bilateral glaucoma (140.10, H40.20), report only one code for the type of glaucoma with a 7" character for the stage. ¢ When the patient has bilateral glaucoma and each eye is a different type - and the classification does not distinguish laterality (H40.10, H40.20), assign a code for each type of glaucoma with the appropriate 7" character for the stage. * When a patient has bilateral glaucoma and each eye is the same type, but different stage, and the classification doesn’t distinguish laterality (H40.10, H40.20), assign a code for the type of glaucoma for each eye with the 7 character for the glaucoma stage for each eye. Glaucoma is classified according to the type of angle closure. The angle referenced is along the exterior ring of the iris, where it joins the trabecular meshwork at the base of the comea. This meshwork drains aqueous humor from the eye via the anterior chamber so it can be recirculated in the eye. If the angle is closed, the flow of aqueous is reduced or shut off, creating a surplus of aqueous and raising the pressure within the eye. Closed-angle glaucoma is also known as narrow-angle glaucoma. Increased pressure causes the iris to bulge forward narrowing or blocking the drainage angle formed by the cornea and iris. Acute closed-angle glaucoma occurs quickly — within minutes or hours following an injury to the eye. Chronic closed-angle glaucoma can be due to a defect caused by iliness or age. Open-angle, also known as wide-angle glaucoma (chronic glaucoma), is the most common type of glaucoma, and is the leading cause of blindness in adults in the United States. The pressure increases gradually in the eye due to clogging of the drainage system or overproduction of aqueous gel. It can only be detected by regular eye exams. Strabismus (H49-150)—Coordinated eye movement is essential to depth perception, single vision, and other aspects of sight. When the eyes do not move in synchrony, it is often because of misalignment or mismatched strength in the eye muscles. The eye muscles come in three pairs: Superior and inferior rectus, on top and bottom; lateral and medial rectus on each side; and superior and inferior oblique, across the top and bottom of the eyeball. Variations in strabismus are called tropias. In esotropia, the eye deviates inward; in exotropia, outward. In hypertropia, the eye deviates upward; and in hypotropia, downward. Usually, these disorders are corrected in childhood, but illness or injury can sometimes cause strabismus in adults. Balance is restored to the eyes by lengthening or shortening the eye muscles. Injury—Most eye injury codes are in Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88). For example: To code acute chemical conjunctivitis, look in the ICD-10-CM Alphabetic Index for Conjunctivitis/chemical (acute) H10.21-. In the Tabular List, H10.21 has a note to code first from T51-T65 to identify chemical and intent. Superficial injury to the eye and adnexa is reported with codes from category S05, with subcategories for the type of injury and with or without the presence of a foreign body. Codes for burns to the eye and adnexa are in category T26, with the distinction made between burns and corrosions. Corrosions are the result of chemicals while burns are the result of a heat source, such as fire, steam, electricity, or radiation.
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems ICD-10-CM lists many of the codes for eye disorders or injuries based on which eye is affected (left, right, bilateral, or unspecified). Note that documentation for eye care may utilize different abbreviations for right and left. Right is typically documented 0D, left OS, and both eyes, OU. Subcategory codes T85.2 and T85.3 are used for complications of intraocular lens or other ocular prosthetic devices, implants, or grafts. Use codes from these categories if there isa mechanical complication due to corneal graft (T85.31-), or for a displacement of an artificial intraocular lens (T85.32-). Report complications of a corneal transplant with codes from subcategory T86.84-. Intraoperative and postprocedural complications codes (H59) are used if cataract fragments remain in the eye following cataract surgery (H59.02-), or if an accidental puncture to the eye occurs during the surgical procedure (H59.2-). Codes in some categories also identify whether the condition affects the upper eyelid or the lower lid. H02.84- Edema of eyelid H02.841 Edema of right upper eyelid H02.842 Edema of right lower eyelid H02.843 Edema of right eye, unspecified eyelid H02.844 Edema of left upper eyelid H02.845 Edema of left lower lid HO2.846 Edema of left eye, unspecified eyelid H02.849 Edema of unspecified eye, unspecified eyelid il 1 Strabismus (-'\_ f"\ Normal Ty gy @ ®5 Esotropia - eye turns inward /——'\ /\ s ' Exotropia - eye turns outward /——'\ ’—\ e s A Hypertropia - eye turns upward e =N 8- “@ ' Hypotropia - eye turns downward Tropias | ) The Ear Most disorders of the ear fall into the following categories: ¢ Infection and inflammation » Neoplastic disease ¢ Injury « Vertigo ¢ Hearing loss ¢ Congenital disorders Infection and Inflammation—When the patient has an infection or inflammation, first determine the location. The diagnosis codes within Diseases of the ear and mastoid process (H60-H95) are organized by anatomic site, beginning with external ear, moving to middle and inner ear, hearing loss, and ending with codes describing intraoperative and postprocedural complications and disorders. Some ear infection codes are in chapter 1 Certain infectious and parasitic diseases. Some examples are A88.1 Epidemic vertigo, B02.21 Postherpetic geniculate ganglionitis and B00.1 Herpes simplex otitis externa. Report the infectious agent as an additional diagnosis, if known for example, B96.3 Hemophilus influenzae [H. Influenzae] as the cause of disease classified elsewhere or B95.5 Unspecified streptococcus as the cause of diseases classified elsewhere. 7
Chapter 15: Eye and Ocular Adnexa, Auditory Systems By far the most common codes used in this chapter are for otitis media (OM), a middle ear infection. In OM, the infection occurs between the eardrum and the oval window. Some infections are difficult to destroy and become chronic. Other infections are sudden onset and acute. Codes for OM are selected based upon whether the infection is acute or chronic, and whether there is pus, or viscous fluid, or mucous. OM typically follows an upper respiratory infection with the infective agent traveling along the Fustachian tube into the middle ear. The ICD-10-CM codes listed for otitis media are reported by laterality (right, left, or bilateral). Suppurative otitis media in the right ear. Look in the ICD-10-CM Alphabetic Index for Otitis/media/suppurative H66.4-, In the Tabular List, a 5 character is required to identify the laterality. H66.40 Suppurative otitis media, unspecified, unspecified ear HE66.41 Suppurative otitis media, unspecified, right ear HE66.42 Suppurative otitis media, unspecified, left ear H66.43 Suppurative otitis media, unspecified, bilateral Neoplastic Disease—Acoustic neuroma, also called a vestibular schwannoma, is likely the most common neoplasm related to the ear. It is a slow growing tumor of the eighth cranial nerve (vestibulocochlear) connecting the inner ear to the brain. Although benign, it causes problems for the patient because it interferes with balance and hearing and is usually excised. Acoustic neuroma is reported with D33.3 Benign neoplasm of cranial nerves. The Table of Neoplasms has a fairly complete listing of subcategory sites under Ear, but always begin in the Alphabetic Index to ensure the code is listed in the Table of Neoplasms. Injury—Most ear injury codes are found in chapter 19 of ICD-10-CM. Open wound codes are selected based upon the site damaged. Superficial injuries are not specified to a high level of detail because the superficial ear does not include any of the components vital to hearing. The selection of ear injury codes is straightforward. For injuries, 7* character extensions are required to identify the episode of care. Refer to ICD-10-CM guideline 1.C.19.a for the definitions of the 7 characters. Vertigo—Vertigo is an illusion of movement. A person with vertigo feels he is moving or the surroundings are moving when they are not. Vertigo is usually classified as being peripheral or central in origin. Peripheral vertigo is caused by disease in the inner ear, such as neuroma, trauma, inflammation, or infection. Central vertigo is generally milder, and arises from brain pathology (for example, in a patient with multiple sclerosis). There are numerous tests to determine the origin of the vertigo. Vertigo can be a symptom (R42) or, if the cause is known, reported with a code from category H81. Méniére’s disease is the most common form of peripheral vertigo. The cause is unknown; although, the cause of the symptoms is thought to be increased pressure in the endolymph of the cochlea. Vertigo is accompanied by hearing loss and tinnitus, or ringing in the ears. Vertigo can cause nystagmus or reflexive jerky eye movements as a response to the messages of the inner ear. Hearing Loss—ICD-10-CM differentiates conductive hearing loss from sensorineural hearing loss (H90-H94). Conductive hearing loss has its origin in the continuity of the transmission of sound from the external ear across the tympanic membrane through each of the ossicles and across the oval window to the round window and into the cochlea. Any disruption in the conductive chain can cause hearing loss. The site of the disruption is reported in addition to its laterality. Sensorineural hearing loss occurs along the nerve conduction beginning in the cochlear nerve and traveling to the brain. Sensory hearing loss is defined as a defect in the cochlea, and neural hearing loss identifies a problem between nerve hair cells and nerve fibers in the brain. ICD-10-CM includes codes for mixed types of hearing loss. Congenital Disorders—Many chromosomal syndromes have anomalies of the ear as a component. Typically, the individual anomaly treated is reported in addition to the code for the syndrome itself; for example, many children born with Down’s syndrome (Q90.-) also have some form of hearing loss. Other syndromes occur with microtia or less visible defects to the ear. A combination of codes from Diseases of Ear and Mastoid Process (H60-H95) and the congenital section for the ear ((16-Q18) may be necessary to capture the complete clinical picture. Symptoms and Z Codes There may be instances when symptoms or a screening is the reason to seek services from a provider. ICD-10-CM chapters 18 and 21 have codes for these circumstances. Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) has generic codes for vertigo when a link to vestibular disease has not been established (R42) and codes for abnormal test results when the diagnosis is still unknown (R94-). In chapter 21, there are codes for family history of deafness, and ear disorders classifiable to H60-H83, H92-95. There are codes identifying the reason for the encounter as a hearing exam and aftercare of surgery on the sense organs. Be sure to validate code section in the Tabular List. Ear examination Look in the ICD-10-CM Alphabetic Index for Examination/ear Z01.10 Z01.10 Encounter for examination of ears and hearing without abnormal findings. Acronyms AACG acute angle dosure glaucoma AU both ears AC antenor chamber BOM bilateral otitis media AD nght ear BSOM bilateral serous otitis media AMD age related macular degeneration CACG chronic angle closure glaucoma AS left ear CE cataroct extraction
Chapter 15: Eye and Ocular Adnexa, Auditory Systems DA dark adaptation oD right eye ERG electroretinogram oS left eye ETD Eustachian tube dysfunction ou both eyes FA fluorescein angiography PCIOL posterior chamber IOL FB foreign body PMMA polymethylmethacryiate FIG fulltime glasses POAG prnmary open angle glaucoma GDD glaucoma drainage device PSC posterior subcapsular cataract GP gas permeable RD retinal detachment IOL intraocular lens RK radial keratotomy 1OP intraocular pressure ROP retinopathy of prematurity LL lower lid T&A tonsils and adenoids LOM left otitis media ™ trabecular meshwork LSOM left serous otitis media ™ tympanic membrane NLD nasal locrimal duct VALE visual acuity, lefl eye NLDO nasal lacrimal duct obstruction VARE visual acuity, nght eye NPDR nonproliferative diabetic retinopathy VF visual field OAG open angle gloucoma WNL within normal lirmits Section Review 15.2 1. The patient is a 40-year-old male with type 1 diabetes in good control. He is seen today for a follow up of his mild nonproliferative diabetic retinopathy in his left eye. Select the correct diagnosis code(s). A. E10.3291, H35.022 B. E10.3292 C. H35.22 D. E11.3293 Answer: B. E10.3292 Rationale: In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic/type 1/with/retinopathy/non-proliferative/mild and directs you to E10.329-. In the Tabular List, 7™ character 2 is reported to indicate the left eye. This is a combination code that includes the diabetes and the complication of retinopathy. A separate code for retinopathy is not reported. Because macular edema is not indicated in the scenario, the default is without macular edema. 2. Mrs. Johns brought in her 9-month-old baby today, complaining that he has been fussy and inconsolable. Indeed, James cried during the entire visit. Mrs. Johns believes her child has another case of otitis media as this is the exact behavior exhibited last time. However, the exam reveals no infection, no fever. Select the correct diagnosis code. A. Z01.10 B. Z00.129 C. H66.90 D. Re8.12 [Hide Answer a ] Answer: D. R68.12 Rationale: Look at the chief complaint — the reason for the visit — when considering the primary diagnosis. In the ICD-10-CM Alphabetic Index, look for Fussy baby directing you to code R68.12. In this case, the mother thought her son had a recurring ear infection because of the child’s excessive crying. D is the correct answer because it is the chief complaint and no other diagnosis was found. Codes Z00.129 and Z01.10 are inappropriate because these codes describe routine exams in asymptomatic populations. Code H66.90 is incorrect, as no definitive diagnosis is made.
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems 3. A patient had an acoustic neuroma removed. The pathology report comes back and the tumor is reported as a malignant tumor of the vestibulocochlear nerve (auditory vestibular nerve). What is the correct diagnosis code? D49.89 B. D333 C. Cr2.40 D. C71.0 Answer: C. C72.40 Rationale: In the ICD-10-CM Alphabetic Index look for Neuroma/acoustic (nerve) D33.3. Although an acoustic neuroma is indexed to D33.3, the question indicates malignant which changes the way the diagnosis is reported. When you look up references to acoustic neuroma you will see that it is a benign tumor that usually grows slowly. A note at the beginning of the Table of Neoplasms discusses classifications in the columns of the table, and advises, “the guidance in the index can be overridden if one of the descriptors ... is present.” Because the pathologist stated this particular acoustic neuroma is malignant, the word malignant overrides the Index entry. Look in the Table of Neoplasms for Neoplasm, neoplastic/auditory/nerve/Malignant Primary which directs you to C72.4-. Verify in the Tabular List and code C72.40 is reported because the laterality is not addressed. It's very important to study and understand the information provided in the guidelines and notes within the code book. Be willing to look beyond the codes for the answers because the answers may be in the instructional notes and guidelines. 4. While dressing for work, the patient caught her earring in her shirt, and the force of her arm’s motion ripped the earring free, tearing her earlobe. She is seen in the emergency department to have the left earlobe repaired and to receive a tetanus shot. What diagnosis codes are assigned? A. SO01.311A,723 B. S01.332A,723 C. S01.342A,723 D. S01.312A,723 Answer: D. S01.312A, 723 Rationale: This is an open wound of the earlobe. In the ICD-10-CM Alphabetic Index look for Laceration/ear (canal) (external), which directs you to S01.31-. In the Tabular List, the code selection indicates a 6™ character for laterality and 7 character to indicate the episode of care is required. Complete code S01.312A is for laceration of the left ear, initial encounter. The patient received a vaccination for tetanus, which is reported with Z23. Look in the Alphabetic Index for Vaccination/encounter for directs you to Z23. 5. A child is exhibiting leukocoria in the left eye, and an MRI of the skull is ordered to rule out retinoblastoma. What diagnosis code is reported? A. Ha44532 B. (69.22 C. H17.12 D. H44.50 Answer: A 1144.532 Rationale: Look in the ICD-10-CM Alphabetic Index for Leukocoria and you are directed to see Disorder, globe, degenerated condition, leukocoria. Disorder/globe/degenerated condition/leukocoria directs you to H44.53-. In the Tabular List, 6™ character 2 is reported to indicate the left eye. Leukocoria reports a symptom rather than an actual diagnosis. In leukocoria, an abnormal white reflection from the retina is visible through the pupil upon examination of the eye. It can be indicative of retinoblastoma, a congenital retinal cancer, but until this diagnosis is confirmed, the symptom of leukocoria is the appropriate diagnosis to report. 6. Topical antibiotics were prescribed today for Jack Jones, who presented with pink eye in both eyes. His four children are all being treated for the same condition by their pediatrician. What is the correct diagnosis code? A. H10.021 B. H10.023 C. H10.029 D. H10.519 Answer: B. 1110.023 Rationale: Pink eye is a highly infectious form of mucopurulent conjunctivitis. This infection typically is accompanied by very bloodshot eyes and a heavy discharge. In the ICD-10-CM Alphabetic Index, look for Pink/eye - see Conjunctivitis, acute, mucopurulent. Look for Conjunctivitis/acute/mucopurulent H10.02-. In the Tabular List, the codes contain laterality and documentation indicates both eyes (bilateral) are affected. 10
Chapter 15: Eye and Ocular Adnexa, Auditory Systems 7. Mable reports her hearing is not what it used to be. Indeed, everything that was discussed today during her visit has been repeated loudly, and within very close range. The physician scheduled a hearing testing with Acme Audiology. What is the diagnosis code? H90.8 B. R94.120 C. H91.09 D. H91.90 Hide Answer » Answer: D. H91.90 Rationale: Without more specific information for the type of hearing loss, a nonspecific diagnosis is reported. In the 1CD-10-CM Alphabetic Index, look for Loss/hearing (see also Deafness). Look for Deafness directing you to H91.9-. In the Tabular List, select code H91.90 Unspecified hearing loss, unspecified ear. No scientific study of the hearing loss was made, making R94.120 incorrect. 8. The patient underwent an enucleation for retinal cancer and is here today with right orbital cellulitis, a foreign body response to the temporary implant placed following the surgery. The implant was removed, and the patient was admitted for observation and IV antibiotics. Select the correct diagnosis codes. A. T85.79XA, H05.011,7Z85.840 B. T86.8411,H05.011,780.8 C. Ho5.011,780.8 D. T86.8411,H05.011,785.840 Hide Answer » Answer: A. T85.79XA, H05.011, Z85.840 Rationale: In the ICD-10-CM Alphabetic Index, look for Complication/eye/implant (prosthetic)/infection and inflammation directing you to T85.79-. In the Tabular List, code T85.79- requires a 7™ character. Based on active treatment for the condition this would support A, initial encounter. Because T85.79 is a five-character code the placeholder X is needed to maintain the 7% character position. Subcategory code T85.7 states to “Use additional code to identify specified infections™. There is no documentation of the infective agent. Orbital cellulitis is indexed under Cellulitis/orbit, orbital H05.01-. In the Tabular List, the 6™ character 1 is for the right side. The implant is the result of the patient’s previous cancer indicated with Z85.840. This is found under History/personal (of )/malignant neoplasm (of )/eye Z85.840. This isnot a family history of cancer of the eye, Z80.8. 9. The patient reports she turned her head quickly while pruning a dogwood tree in her yard and a branch entered her right ear. She states that when she performs a Valsalva maneuver (exhaling with the mouth and nose firmly closed), she can hear air course through her ear. On examination, there is no foreign body present. A small perforation of the right eardrum is noted, which should heal independent of treatment. Her ear will be re-evaluated in two weeks. Select the correct diagnosis codes. H72.01, W60.XXXA, Y92.017,Y93.H2 S00.401A, H72.00 = C. S$09.21XA,W60.XXXA,Y92.017,Y93.H2 D. S09.21XA, W45.8XXA,Y92.017,Y92.157 Answer: C. S09.21XA, W60.XXXA,Y92.017, Y93.H2 Rationale: This is an acute injury and in ICD-10-CM injuries have different categories for open wounds, lacerations, bites, and are specific to with or without a foreign body. In the ICD-10-CM Alphabetic Index, look for Wound/puncture wound - see Puncture. Look for Puncture/ear/drum directing you to S09.2-. In the Tabular List subcategory S09.2- requires a 5™ digit for laterality and a 7" character for the type of encounter. Because S90.21 is a five-character code, the place holder X is needed to maintain the 7 character position. The complete code is S09.21XA. Codes in the H72.0- subcategory are for perforations persisting after an illness or injury is resolved. Code S00.401- is for a superficial injury, but this isn't superficial because it is in the middle ear. Do not confuse simple with superficial. External cause codes describe the circumstance of the injury. These codes are found in External Cause of Injuries Index. Look for Contact/with/plant thorns, spines, sharp leaves or other mechanisms W60. Category W60 requires a 7" character for type of encounter. Because this is a three-character code, the placeholder X is needed to maintain the 7* character position. The complete code is W60.XXXA. Next, in the External Cause of Injuries Index for look for Place of occurrence/yard, private/single family house Y92.017. In the same index look for Activity/gardening Y93.H2. Verify these codes in the Tabular List. These External cause codes help establish the cause of the injury for the payer. 10. The patient has been compliant with his Xalatan eye drops, and his intraocular pressure (10P) is now within normal limits at 20 mm Hg. The glaucoma seems to be in good control. He will continue the current regime and return for a follow-up exam in six months. What diagnosis code is reported? = C D. H40.9 H40.10X0 786.69 H40.20X1 Answer: A. H40.9 Rationale: There is not a lot of information to work with and H40.9 Unspecified glaucoma is the appropriate choice. In the ICD-10-CM Alphabetic Index, look for Glaucoma and the default code is H40.9. In a medical office, you would have access to the entire patient record and to the physician to find out more about the type of glaucoma. The important thing to remember is the patient still has glaucoma, despite the normal (WNL is within normal limits) IOP (intraocular pressure). Code 7Z86.69 is inappropriate because it reports a history of a resolved condition. 11
Chapter 15: Eye and Ocular Adnexa, Auditory Systems CPT® There are codes throughout the CPT® code book used to report procedures on the eye and ear. Codes for flaps and repairs performed on the skin of the eye and ear are in the Integumentary section. The codes specific to Eye and Ocular Adnexa (65091-68899) and Auditory System (69000-69979) are almost exclusively reported by specialists, with a few exceptions, because, of the complexity of these organs and the skills required to perform surgeries on them. Eye and Ocular Adnexa Eyeball (65091-65290) The Eye and Ocular Adnexa section begins with a sequence of codes for the most extreme procedures performed on the eye: its removal. An eye typically is removed for one of three reasons: the eye has a malignancy, and its removal is to safeguard the patient’s health; the eye is blind and very painful, and its removal is to relieve the patient’s symptoms; or the eye is blind and disfiguring, and the patient will receive a cosmetic implant in its place. There are three types of removals. Evisceration is when the contents of the eyeball are scooped out but the sclera shell remains connected to the eye muscles so a prosthesis fitted into the globe will have natural movement. In enucleation, the connections (muscles, vessels, and optic nerve) are severed and the entire eyeball is removed en masse. In exenteration, surrounding skin, fat, muscle, and bone are removed. Exenteration is the most extreme type of surgery and is reserved for patients who have serious malignancies. In any removal, a temporary implant may be placed to protect the void that will later hold a permanent implant. This temporary implant is included in the procedure and not reported separately. The implant codes reference permanent implants that have aesthetic properties. Anterior Segment (65400-66999) Procedures that cut into the globe or the anterior segment of the eye disturb its fluid balance and invite the possibility of infection. A laser is used to surgically cauterize, cut, destroy, or repair the eye, instead of a knife. The laser light can enter through the cornea directly to any site in the globe without incision or causing harm. The targeted light is focused on the defect. Lasers are very specific in what they can do, which is why a laser approach is preferred to an open approach. Comea The excision of a lesion of the cornea is a surgical procedure (for example, keratectomy, lamellar, partial. Lamellar refers to partial thickness of the cornea). An excision is the removal of an entire defect while a biopsy is removal of tissue for a diagnostic examination. PRACTICAL CODING NOTE Never report codes 65400 and 65410 together on the same date of service. The biopsy is considered inclusive of the excision. A pterygium is a benign growth of the conjunctiva attached to the sclera and extends from the inner canthus to the border of the cornea with an apex that points to the pupil. A pterygium may require surgical excision or transposition when it is blocking the field of vision. A circumcorneal incision may be accomplished with the use of a conjunctival flap to repair a pterygium site following excision or transposition. CPT* codes found under the category for removal or destruction include a diagnostic scraping of the cornea to obtain a smear and/or culture. The tissue removed during scraping (65430) may be cultured to determine a diagnosis. Removing the epithelial layer by scraping or cutting will stimulate the growth of the comea’s outermost layer to treat cases of corneal erosion or degeneration. CPT* 65435 reports removal of comneal epithelium with or without chemocauterization by abrasion or curettage. When a rust ring is removed from the cornea, chemical cauterization may be applied. An alternative to the chemocauterization procedure is the use of an acid to destroy the corneal epithelium. CPT® 65436 reports the application of a chelating agent such as EDTA. Multiple punctures of the anterior cornea to treat corneal erosion (65600) are done in an attempt to stimulate growth of the cornea’s outermost layer. A fine needle is used to tattoo the epithelium surface by creating hundreds of tiny pricks. Keratoplasty is the plastic repair of the cornea. This procedure is also known as a comeal transplant. It includes the use of fresh or preserved grafts and preparation of donor material for cornea transplant. Keratoplasty procedures are normally performed using an operating microscope. A patient diagnosed with peripheral opacity of the cornea, anterior, stromal, or posterior pigmentation of the cornea, or keratoconus, might undergo a keratoplasty that includes a lamellar comeal transplant. A lamellar corneal transplant refers to the thin, outermost layers (not usually deeper than the stroma) of the cornea. A trephine is used to punch a measured circular hole in the cornea of the donor eye, and the corneal tissue is prepared and set aside. This process is repeated in the comea of the patient and the defective tissue is removed. The identically sized donor material is sutured into position. CPT® 65710 reports a lamellar keratoplasty. A penetrating corneal transplant refers to a full-thickness corneal transplant {(65730-65755). The procedure is similar to the lamellar transplant except the donor material is full thickness. In aphakic patients, vitreous or aqueous may be withdrawn from the eye prior to corneal removal. An aphakic patient is a patient who has had cataract surgery and does not have an artificial or natural lens. A key consideration when determining a code for keratoplasties is determining the lens status of the patient. Aphakia is the absence of the lens of the eye. CPT® 65750 reports a keratoplasty for an aphakic patient. CPT* 65755 reports a keratoplasty; penetrating for the pseudophakic patient. A pseudophakic patient is one who does not have a natural lens but an artificial intraocular lens (I0L). PRACTICAL CODING NOTE CPT* codes 657 10-65757 are not used to report refractive keratoplasty procedures for the fitting of contact lens for treatment of disease. Code 92072 is reported for this purpose. Keratomileusis (65760) is a procedure to alter visual acuity. In this procedure, a partial-thickness central portion of the comea is frozen, reshaped on an electronic lathe, repositioned, and sutured back into place. This procedure to correct high degrees of myopia has largely been replaced by photorefractive keratectomy (PRK) and LASIK, a noninvasive surgery in which an Excimer laser is used to reshape the cornea of the eye. In PRK, the cornea’s entire epithelial layer is removed to expose the area, whereas in LASIK surgery a thin, hinged flap is created on the cornea to access the treatment area to reshape the stromal layer of the comea to correct the refractive error. CPT* code 66999 reports PRK and LASIK procedures. Include a letter and operative report with the claim. In a keratophakia procedure (65765), a trephine is used to punch a measured circular hole in the cornea of the eye. An incision is made at the juncture of the cornea and the sclera. The patient’s cornea is then separated into two layers. The donor comea is inserted between these layers. This change in corneal curvature corrects a preexisting refractive error. Refractive corrections are generally cosmetic and may not be reimbursable. 12
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems In an epikeratoplasty procedure (65767), the trephine punches measured circular holes in the comnea of the eye. A lens, made up of the stroma and the Bowman’s membrane layers of the cornea, is shaped on a lathe. This lens is sutured into position on the surface of the patient’s comea correcting a preexisting refractive error. A new anterior chamber is created with a plastic optical implant replacing a severely damaged cornea in a keratoprosthesis procedure (65770). In a radial keratotomy (6577 1) procedure, the patient's cornea is measured and multiple, nonpenetrating cuts are made in a bicycle spoke pattern on the cornea to reduce myopia. A variety of peripheral cornea tangential cuts may be made for astigmatic correction. This procedure is often performed with circumferential subconjunctival or retrobulbar block anesthesia. PRACTICAL CODING NOTE Photorefractive keratectomy and LASIK are reported with the unlisted code 66999. If previous surgery results in astigmatism, corrective surgery is performed. In this corneal relaxing procedure (65772), an X cut is made on the cornea to repair the error. Slices along the edge of the cornea are removed. In corneal wedge resection (65775), a wedge is cut from the cornea. The wedging procedure is the most preferred technique used by surgeons to correct surgically induced astigmatism. Corneal incisions or wedges for correction of surgically induced astigmatism require diagnosis codes of H52.2- Astigmatism, T85.3- Mechanical complication of other ocular prosthetic devices, implants and grafts, 794.7 Corneal transplant status, 798.4- Cataract extraction status, and 798.83 Filtering (vitreous) bleb after glaucoma surgery status. The surgically induced astigmatism should be two diopters or more of change documented pre- and postoperatively and not resolved by spectacles. The corneal epithelium is a five- to seven-cell-layer thick covering of the anterior surface of the cornea, which protects the interior cornea from foreign objects and helps produce tears with secretions on the front surface of the superficial epithelial cells. Ordinarily, superficial cells are shed from the epithelial surface and replaced by those from below and basal epithelial cells replace the deeper corneal epithelial cells. A constant supply of comeal epithelial cells is required and an interruption (e.g., due to chronic conditions such as radiation keratitis, drug toxicity, and ocular cicatricial pemphigoid) can cause serious ocular problems. Chronic inflammation may occur characterized by corneal scarring and opacification, corneal thinning, and possible corneal perforation, all of which may lead to loss of visual acuity. Insufficient corneal epithelial stem cells in the limbal region can be caused by burn injuries or Stevens-Johnson syndrome, an acute inflammatory disorder of the skin and mucous membranes. Treatment of chronic epithelial defect includes limiting or removing its causes. Effective therapy includes frequent topical lubrication, punctal occlusion, and therapeutic contact lenses. More invasive surgical therapies include temporary or permanent tarsorrthaphy (sutures are used to close the palpebral fissure at least partially) (67875) and the use of human amniotic membrane for transplantation (65780) may be an alternative or adjunctive therapy. Other alternative procedures include limbal cell allografts from a cadaver or living donor (65781). Corneal tissue relies on stem cells located in the limbal epithelium, the zone where corneal and conjunctival epithelia meet, to regenerate. If the graft is taken from a living donor, a conjunctival limbal graft is placed with the limbal edge of the graft at the recipient limbus. Code 68371 reports harvesting of an allograft. A limbal conjunctival autograft (65782) includes obtaining the graft from the healthy eye. CPT® 65785 reports implantation of intrastromal corneal ring segments. This procedure is performed for the treatment of keratoconus, which is a corneal disorder where progressive corneal thinning causes irregular astigmatism and decreased visual acuity. The segments are implanted in the deep corneal stroma to modify the comeal curvature. Anterior Chamber A paracentesis procedure (65800-65815) is performed for the removal of aqueous humor from the anterior chamber for diagnostic analysis or to quickly reduce eye pressure temporarily as a therapeutic procedure. Code 65810 describes paracentesis of the anterior chamber with removal of vitreous and/or discission (cutting into or incision) of the anterior hyaloid membrane. This is usually performed with a YAG (yttrium-aluminum-garnet) laser. The anterior hyaloid membrane is a layer of collagen separating the vitreous from the lens. The posterior hyaloid membrane separates the back of the vitreous from the retina. Surgeries on the iris and trabecular meshwork, including goniotomy, are usually a therapeutic treatment for glaucoma to improve the flow of aqueous in the eye. This disease is characterized by increased intraocular pressure. If left untreated, it will damage the optic nerve and retina, causing blindness. A goniotomy (65820} is a surgical procedure for children in which a lens (goniolens, gonioscopy lens) is used to see the anterior chamber and an opening is made in the anterior trabecular meshwork. A trabeculotomy (65850) is a procedure to create an opening in the meshwork for the drainage of aqueous humor. A trabeculotomy is performed on children to treat congenital glaucoma. Trabeculoplasty is the repair of the trabecular meshwork by laser surgery in one or more sessions. Code 65855 reports a trabeculoplasty by laser surgery. In all other references surgery by laser, one or more sessions include all additional treatments to the same eye in a defined period. Code 65860 reports the severing of goniosynechiae (adhesions of the iris to the posterior surface of the cornea) before they cause a more serious problem. Codes 65865-65875 report the incisional technique for severing adhesions in the anterior segment of the eye including anterior and posterior chamber synechiae. An instructional note states to use code 65855 for trabeculoplasty performed by laser surgery. Anterior Sclera Anterior sclera includes excision, aqueous shunt, and repair or revision codes. Iris, Ciliary Body An iridotomy (66500) is an incision into the iris. A patient diagnosed with adhesions or disruptions of the pupillary membranes (for example, iris bombe), occlusion or seclusion of the pupillary membrane may require an iridotomy procedure (incision into the iris). Iris bombe is a condition where iris bulges forward into the anterior chamber due to pressure built up from an accumulation of agueous fluid between the iris and the lens in the posterior chamber. The surgeon makes an incision in the corneal-scleral junction (limbus), and then slices through the iris in a side-to-side technique (66505). This procedure increases the flow of the fluids that was initially slowed due to pupillary blockage. No tissue is removed in this procedure. An iridectomy is the removal of part of the iris. To remove a lesion from the iris, a surgeon may choose to perform an iridectomy with a corneoscleral section or corneal section (66600). Using deep laser burns, an incision is made through a conjunctival flap. An argon laser is used to excise the affected iris along with other involved structures. A cyclectomy (66605) consists of removing part of the ciliary muscle along with the lesion. The ciliary muscle is a ring of striated smooth muscle of the ciliary body that is attached to the lens. This muscle controls accommodation by changing the shape of the lens and regulates the flow of agueous humor into Schlemm’s canal. 13
Chapter 15: Eye and Ocular Adnexa, Auditory Systems A patient with degeneration of the iris and ciliary body (iris atrophy, iridoschisis, translucency of the iris, miotic cysts of the pupillary margin, or changes in the chamber angle) may require a surgical procedure to repair or suture the iris (66680) and ciliary body (66682). The surgeon places an ocular speculum in the patient’s eye and makes an incision in the limbus to approach and repair a tear of the iris. These types of tears are often the result of bleeding from the torn tissues due to trauma. Any bleeding is controlled by cautery and the iridodialysis (coredialysis, or localized separation/tearing of the iris from the ciliary body) is sutured with fine surgical thread. The surgically created iridectomy site remains open. In cases where high intraocular pressure cannot be otherwise controlled, portions of the ciliary body are destroyed to reduce the production of aqueous humor. Codes 66700-66740 report the use of a heat probe, laser, or freezing probe. Cyclodialysis (66740) involves an incision and insertion of a spatula that separates the ciliary body from the sclera spur to lower intraocular pressure either by decreasing aqueous humor formation or by increasing uveovascular scleral outflow of agueous. In an iridotomy/iridectomy procedure, part of the iris is removed, or an incision is made into the iris to permit aqueous flow from the posterior chamber to the anterior chamber, reducing intraocular pressure. A slit-lamp microscope and laser are used together to facilitate this procedure. Lens and Intraocular Lens Procedures An intracapsular cataract extraction (ICCE) is when the physician removes the cataract lens and capsule as one and inserts a lens prosthesis The ICCE procedure is seldom performed today due to the availability of more advanced techniques. When an extracapsular cataract extraction (ECCE) is performed, the posterior part of the lens capsule remains intact. At times, this structure may become opaque or membranes may grow secondary to the original procedure (secondary membranous cataract). Opaque membranes are excised with a needle knife or laser. When coding incision of secondary cataract, it’s important to differentiate between the techniques of stab incision or laser surgery. 5 Procedure 66820 describes a cut into the limbus to access and remove a secondary cataract. Today, this procedure is performed by laser: An upside-down U is cut through the secondary cataract, which then falls out of the visual field like an opened curtain. This type of laser incision is reported with 66821. Some surgeries require incisions. Removal of a lens with a cataract requires an incision allowing the lens to be extracted and an intraocular lens (I0L) inserted. Currently, cataract surgery is performed microscopically, and tiny incisions in the limbus fulfill the code requirement. The defective lens is broken down into smaller segments and systematically vacuumed from the eye. The artificial lens is folded in on itself and inserted through the incision. When in place, the artificial lens opens and is secured. Recovery is a fraction of what once was required for cataract surgery. During laser surgery, the pupil is typically dilated allowing the physician to have a broader view and greater ability to reach more tissue in the eye. A speculum is placed in the eye to hold it open, and anesthetic is applied to the cornea. For some surgeries, injections are required to numb the eye. Retrobulbar, suprachoroidal space, and Tenon’s capsule injections are all approaches for delivery of anesthetic. These nerve blocks are bundled into the procedures and not reported separately when performed by the surgeon. The majority of procedures performed on the anterior segment of the eye are considered microsurgeries as they are performed using an operating microscope (69990). The scope is not reported separately for procedures 65091-68850. All procedures that include use of an operating microscope are listed in the section note above code 69990. Posterior Segment (67005-67299) Vitreous A vitreous hemorrhage is an extravasation (leaking) of blood into the vitreous. It often produces a black reflection on ophthalmoscopy. A vitreous hemorrhage may occur in such conditions as retinal vein occlusion, diabetic retinopathy, posterior vitreous detachment, retinal neovascularization, retinal tears, or ocular trauma. Localized bleeding from retinal vessels can usually be controlled by photocoagulation. Vitreous hemorrhages, along with diagnoses such as degeneration, crystalline deposits, prolapse, or other disorders of the vitreous, are health issues that warrant the surgeon to recommend a procedure to remove the vitreous. A vitrectomy is the surgical removal of part or all of the vitreous (a clear jelly-like substance that fills the posterior [rear] cavity of the eyeball). An open sky technique, as described in code 67005, refers to an incision made at the corneal edge or limbus. A needle is passed to the back of the anterior segment where displaced vitreous humor is removed by aspiration. If the vitrectomy is performed with a mechanical tool instead of a syringe, code 67010 is reported. Some of the codes in the Vitreous category of CPT* refer to a pars plana approach. The pars plana refers to the flattened posterior portion of the ciliary body located 4 mm behind the comeoscleral junction. Sometimes during cataract extraction surgery, the vitreous moves forward into the wound and this material must be removed. This removal procedure (67015) may be coded in addition to the cataract surgery, depending on payer reimbursement policies. Code 67025 reports the injection of a vitreous substitute and refers to the injection of Healon or silicone and not air or balanced salt solutions. During a vitrectomy procedure, part or all of the vitreous may be removed. Special instruments, such as Roto-extractor or vitreous infusion suction cutter (VISC), are used. A VISCis capable of aspirating, cutting, and removing vitreous and at the same time, introducing irrigating fluid into the posterior cavity. A panretinal procedure means that all four quadrants of the retina are treated. Code 67040 reports a vitrectomy with endolaser panretinal photocoagulation. Retina or Choroid Retinal detachment is a separation of the retina from underlying retinal pigment epithelium. A retinal detachment is painless. Early symptoms may include vitreous floaters, flashes of light, or blurred vision. Direct ophthalmoscopy can indicate retinal irregularities and a bullous retinal elevation with darkened blood vessels. Retinal detachments may be caused by injury, previous surgery, inflammation, and vitreous hemorrhage. This condition occurs when the inner layer of retinal tissue falls away from the underlying support tissue into the vitreous. Because the tissue is detached from its choroid blood supply, vision is lost in that part of the retina. Cryotherapy refers to the use of subfreezing temperatures to destroy tissue, while diathermy uses high frequency electric currents for the same purpose. Photocoagulation uses a laser to coagulate and destroy the tissue. Codes 67101-67113 require a diagnosis of retinal detachment. It is quite common to confuse the use of posterior segment codes with or without retinal detachment. The operative report must be reviewed carefully to determine the appropriate CPT® code to report from this code group. If several methods are combined, such as diathermy, cryotherapy, and photocoagulation, report the code describing the principal modality. Also, note that several of these codes do not allow for separate reporting of implants or drainage of fluid. Retinal breaks and lattice degeneration detachments may require a procedure to secure the retina by cryotherapy or by diathermy or by photocoagulation. Prophylactic treatments for retinal detachment are coded according to the method used. CPT® notes that the procedure may require one or more sessions. CPT* modifier 58 (staged procedure) should not be attached to these codes because the definitions of these codes denote repetitive services and staging is inclusive. 14
Chapter 15: Eye and Ocular Adnexa, Auditory Systems The choroid is a vascular tunic that is between the sclera and retina. A patient diagnosed with localized lesions of the choroid, caused by age-related macular degeneration, may undergo a procedure requiring ocular photodynamic therapy (OPT) utilizing a photosensitive drug or a laser treatment that treats choroidal neovascularization. The laser procedure (67220) describes destruction of a localized lesion of choroid, one or more sessions, by photocoagulation using laser. Ocular photodynamic therapy (67221) utilizes low energy targeted laser light to activate a photoactive drug administered intravenously to remove abnormal tissue. Ocular Adnexa (67311-67999) There are many procedures performed on the ocular adnexa that do not require entry into the globe or anterior segment. Extraocular Muscles The muscles controlling vertical eye movement are the superior rectus, inferior rectus, superior oblique, and inferior oblique. Muscles controlling horizontal movement include the medial rectus and lateral rectus. Strabismus is an imbalance in the muscles of the eyeball that control movement of the eyeball. & 3 Spois Gobygue adrarrenisd e d otwand mc et Sugee o e lus pward riove ment) Latwey pacney =~ ourseer! moyserent Wedhal rectun Granard rmovermaant) Irdenior recnn 1Eowr vy mon e st Ieforkoe cobgue Six MUSC|eS Controning Eye Movement Jupremard ared cutwertd mesvanmod) ' , 2 Recession is a weakening procedure whereby an extraocular muscle (EOM) is severed from the eye, allowed to retract, and then sutured to the sclera at a selected distance from the original place of attachment. A resection procedure involves detaching the extraocular muscle from the eye, removing part of the muscle tissue, and then resuturing it to the eye, usually at the original site. Codes 67311-67318 are the primary strabismus codes that identify resection or recession procedures used to strengthen or weaken each eye muscle or a combination of eye muscles. Exotropia is when an eye turns outward. A patient diagnosed with exotropia may require this procedure on the horizontal muscles. In some cases, the procedure is not completed until the patient is awake and lengthy sutures extruding from the back of the eye adjusted to ensure perfect binocular vision. These adjustable sutures are reported with add-on code +67335. Orbit Orbitotomies without bone flaps and using a frontal or transconjunctival approach for exploration/drainage to remove lesions, foreign bodies, or bone removal for decompression, are reported using codes 67400-67414. Incisions are made in either the upper or lower eyelid for these procedures. Orbitotomies with bone flaps or windows for exploration with or without biopsy, for removal of lesions, foreign bodies with drainage, or for bone removal for decompression, are reported using codes 67420-67450. These procedures include a C-shaped incision down to the periosteum overlying the lateral orbital rim. Code 67445 is a surgical procedure where a part of the orbital side bone is removed to allow lateral movement rather than pushing the eye forward. A lateral approach (e.g., Kroenlein), is used. This procedure is sometimes necessary in the treatment of Grave's disease. Grave's disease is a thyroid disease that can cause exophthalmos, which is the protrusion of one or both of the eyeballs. Injection procedures include codes 67500-67516. Retrobulbar injections are used to introduce medication or alcohol to the muscle cone behind the eye. Therapeutic agents are introduced by injection along the surface of the globe beneath the conjunctiva and between the sclera and Tenon’s capsule. Tenon’s capsule is a thin membrane which envelopes the eyeball from the optic nerve to the limbus, separating it from the orbital fat and forming a socket in which it moves. A suprachoroidal space injection is a medical procedure where medication is injected into the suprachoroidal space of the eye. This space is located between the sclera (the white of the eye) and the choroid layer (a layer filled with blood vessels that supplies the outer part of the retina). This procedure is often used in the treatment of various eye conditions, such as uveitis, retinal vein occlusion, and certain types of glaucoma. It allows for targeted delivery of medication to the back of the eye, potentially improving the effectiveness of treatment and reducing side effects. Orbit Orbitotomies without bone flaps and using a frontal or transconjunctival approach for exploration/drainage to remove lesions, foreign bodies, or bone removal for decompression, are reported using codes 67400-67414. Incisions are made in either the upper or lower eyelid for these procedures. Orbitotomies with bone flaps or windows for exploration with or without biopsy, for removal of lesions, foreign bodies with drainage, or for bone removal for decompression, are reported using codes 67420-67450. These procedures include a C-shaped incision down to the periosteum overlying the lateral orbital rim. Code 67445 is a surgical procedure where a part of the orbital side bone is removed to allow lateral movement rather than pushing the eye forward. A lateral approach (e.g., Kroenlein), is used. This procedure is sometimes necessary in the treatment of Grave’s disease. Grave’s disease is a thyroid disease that can cause exophthalmos, which is the protrusion of one or both of the eyeballs. Injection procedures include codes 67500-67516. Retrobulbar injections are used to introduce medication or alcohol to the muscle cone behind the eye. Therapeutic agents are introduced by injection along the surface of the globe beneath the conjunctiva and between the sclera and Tenon’s capsule. Tenon’s capsule is a thin membrane which envelopes the eyeball from the optic nerve to the limbus, separating it from the orbital fat and forming a socket in which it moves. A suprachoroidal space injection is a medical procedure where medication is injected into the suprachoroidal space of the eye. This space is located between the sclera (the white of the eye) and the choroid layer (a layer filled with blood vessels that supplies the outer part of the retina). This procedure is often used in the treatment of various eye conditions, such as uveitis, retinal vein occlusion, and certain types of glaucoma. It allows for targeted delivery of medication to the back of the eye, potentially improving the effectiveness of treatment and reducing side effects. 15
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems Eyelids A surgeon may perform a blepharotomy (67700) to drain an eyelid abscess when a patient is diagnosed with a hordeolum or other deep inflammation, abscess, or cysts. The patient is usually placed under a local anesthesia, a small incision is made in the eyelid and the abscess is drained and irrigated. If the abscess or hordeolum is extensive, the provider may place a small drain in the wound. When a patient is diagnosed with an orbital hemorrhage or blepharophimosis (decrease in the size of the fissure between the eyelids without fusion of the eyelid), the provider often performs a canthotomy. A canthotomy (677 15) involves creating an opening into the skin at the canthus to repair its shape. A chalazion is a small, localized swelling, or mass located at the margin of an eyelid. It is often caused by inflammation and blockage of a meibomian gland (tarsal gland), one of the sebaceous glands between the dense white fibrous tissue supporting the eyelid (tarsi) and the eyelid’s conjunctiva. Excision of the chalazion is reported with a code from 67800- 67805, depending on the number of chalazia excised and whether both eyelids are affected. When a patient is seen for ingrown eyelashes (trichiasis) irritating the eye, such as senile entropion, cicatricial entropion, hypertrichosis of the eyelid (abnormal growth of eyelashes), or other disorders of the eyelid, operative intervention may be required. Trichiasis often irritates the comea or conjunctiva, resulting in scarring or thickening of the comea if left untreated. The ophthalmologist may perform a procedure to correct the condition. In the procedure, the surgeon uses a biomicroscope, an instrument consisting of a microscope combined with a rectangular light source, to pluck out the offending eyelashes with forceps. Tarsorrhaphy involves suturing the edges of the eyelids to close the palpebral fissure, which is the linear opening between the eyelids. This temporary closure provides relief for the patient with an eroded or painful cornea. Code 67875 reports when the provider uses Frost sutures for temporary closure of the eyelids. Code 67880 reports construction of the intermarginal adhesions, median tarsorrhaphy or canthorrhaphy (repair of the canthus — the angle of the slit between the eyelids at either end). Permanent intermarginal adhesions are created by excising tissue from the margins of the eyelids along the mucocutaneous junction. Sutures are passed through the eyelid margin and skin of the upper and lower lids. For each eye, the process may be repeated several times. Brow ptosis is the drooping of the eyebrows. This occurs in old age or secondary to paralysis or weakness of the frontalis muscle such as in Bell's palsy or myasthenia gravis. Dissection is carried down to the brow area as the surgeon pulls superiorly to properly position the brow area above the supraorbital rim. Code 67900 reports the repair of a brow ptosis by supraciliary, midforehead, or coronal approach. Blepharoptosis is drooping of an upper eyelid and may require surgical intervention by various techniques. Code 67901 reports the repair of blepharoptosis using the frontalis muscle technique with suture or other material (banked fascia). PRACTICAL CODING NOTE Code 67902 is distinguished from code 67901 in that the sling material is fascia lata — a thin, fibrous tissue transplanted from the thigh. CPT* 67912 reports implanting of an upper eyelid load to correct lagophthalmos. Lagophthalmos is the inability to fully close the upper eyelid, which can result in damage to the cornea by drying out its surface due to lack of moisture. The condition may be present at birth but more commonly it is associated with paralyzing conditions such as Bell’s palsy or stroke. Head trauma and tumors also may cause lagophthalmos. The surgical insertion of a predetermined gold weight into the upper eyelid enables the lid to close more easily. Ectropion is the turning outward of the margin of the lower eyelid and procedures to repair the condition are described in codes 67914-67917. Sutures may be used to shorten the posterior tissues of the eyelid. Thermocauterization (67915) is used to shrink the posterior tissues of the eyelid margin to treat the everted lid. A tarsal wedge of tissue can be excised to eliminate the ectropion with sutures placed to repair the incision. In another of these procedures, a canthotomy incision is made and the tarsal plate is advanced and secured with sutures to correct the condition. Code 67916 reports ectropion correction with excision of a tarsal wedge. Entropion is an inversion of the margin of the eyelid. Repair of this condition involves the use of sutures, thermocauterization, and an excised tarsal wedge with a variation of suture repair. Codes 67921-67924 report the various types of entropion repairs. CPT® codes 67930-67935 report the suture of recent partial-thickness and full-thickness eyelid wounds. These wounds are irrigated and sutured in layers. Codes 67961-67966 report full-thickness excision and repair of the eyelid. In these surgical procedures, a piece of eyelid is excised, and surrounding tissue is rearranged to compensate for the defect. If more than one-fourth of the lid margin is removed, assign code 67966. These codes include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement. Conjunctiva (68020-68899) The categories under the Conjunctiva subheading of CPT® identify the following types of surgical procedures: ¢ Incision and Drainage ¢ [xcision and/or Destruction e Injection » Conjunctivoplasty * Other Procedures o Lacrimal System A conjunctival cyst is an abnormal, thin-walled sac of fluid in the conjunctiva. A sebaceous cyst occurs in the sebaceous gland located in the skin of the eyelid. When a conjunctival cyst or a sebaceous cyst undergoes a procedure in which a vertical or horizontal incision is made in the posterior surface of the eyelid to drain fluid or matter, report 68020. Trachoma (68040) is a chronic and contagious inflammation of the conjunctiva with hypertrophy. This condition is most contagious in its early stages and is transmitted by eye secretions, hand-to-eye contact, or by sharing contaminated articles (towels, handkerchiefs, and eye make-up). After the incubation period, which is about seven days, conjunctival hyperemia, eyelid edema, photophobia, and lacrimation appear, usually bilaterally. Unless treatment is given, a cicatrix (scar) follows. Secondary bacterial infection is also common. The treatment involves the use of trachoma biomicroscopic guidance to evert the eyelid margin and express the conjunctival follicles. An excision of a conjunctival lesion including adjacent sclera may be performed on a patient who is diagnosed with a malignant or benign neoplasm of the conjunctiva. Other diagnoses may include carcinoma in situ of the eye, granuloma, or hyperemia of the conjunctiva. Local anesthesia is provided and a lid speculum is inserted, and the lesion is then excised with a curette. Report 68130 for this procedure. A provider may inject a corticosteroid or antibiotic medication into the subconjunctival space to trear a patient for diagnoses such as keratoconjunctivitis, chronic conjunctivitis, or scleritis. Code 68200 reports a subconjunctival injection. 16
Chapter 15: Eye and Ocular Adnexa, Auditory Systems Conjunctivoplasty is an important part of reconstruction because the conjunctiva is vascularized and provides moisture to the inner aspect of the eyelids and to the anterior sclera. The conjunctiva ends at the limbus; there is no conjunctival covering over the cornea. However, in prosthetics following evisceration, the conjunctiva may traverse an artificial cornea. When the conjunctiva is damaged, buccal mucosa may be harvested and used as a graft (68325). Of note, the conjunctiva forms a cul de sac 360 degrees around the eye. Any foreign body that enters the orbit of the eye must pierce the conjunctiva to get there. The extraocular muscles are rooted into the globe posterior to the cul de sac. CPT® procedural codes for removal of excess skin from the eyelid are found in the integumentary chapter. Blepharoplasty codes in the Eye and Adnexa chapter involve the more complex structures within the eye. During a conjunctival flap procedure (68360, 68362), the conjunctiva is elevated from the Tenon’s capsule and a small tongue of free conjunctiva is advanced via a flap where it is secured with sutures. The lacrimal system serves to keep the conjunctiva and cornea moist through the production, distribution, and elimination of tears. An incision of the lacrimal gland (68400) or in the lacrimal sac (68420) is made to drain abscesses. The lacrimal puncta are small openings in the inner canthus of the eyelids that channel tears produced by the lacrimal gland. A snip incision of the lacrimal punctum is commonly performed for stenosis of the lacrimal punctum, epiphora (overproduction of tears), or tear film insufficiency. A snip incision (68440) to the punctum is made and the punctum enlargement is verified with a dilating probe. For total or partial lacrimal gland removal (68500-68505) an incision can be made either beneath the superior orbital rim or in the lid crease of the upper lid. The lacrimal duct is isolated and dissected from its position in the lacrimal fossa. PRACTICAL CODING NOTE Do not report CPT® code 68500 if the removal is due to tumor. For a biopsy procedure of the lacrimal gland (68510), a portion of the gland is excised for analysis. The lacrimal sac is an enlarged portion of the lacrimal duct that eliminates tears. Excision of the lacrimal sac (68520) requires an incision midway between the nose bridge and medial canthal tendon. The sac is separated and removed. For biopsy (68525), a section of the lacrimal sac is removed. Report 68530 for removal of a foreign body or stone in the lacrimal passages. The surgical access to the site is the same as that for sac removal. For excision of a lacrimal gland tumor, access to the site is also the same as that for gland removal. The tumor is removed with a rim of normal lacrimal gland tissue. If the tumor has invaded the lacrimal fossa, part of the affected bone is removed. Code 68540 reports an excision of a lacrimal gland tumor by frontal approach and code 68550 reports an excision of a lacrimal gland by osteotomy. An osteotomy is an incision into the bone. Lacrimal canaliculi are the two passages that connect the puncta to the lacrimal sac. An injury to the eye may sever this passage. A probe may be used to locate the distal and proximal ends of the canaliculi, and the ends are reattached. The wound is closed with sutures. Code 68700 reports a plastic repair of the canaliculi. Code 68720 reports a dacryocystorhinostomy, which creates a fistula or connection between the lacrimal sac and the nasal mucosa. For a conjunctivorhinostomy procedure (68745-68750), the sac is connected to the nasal mucosa by a series of interrupted sutures. A glass tube or a stent may be inserted (68750) to create a connection between the lacrimal system and the nasal mucosa. Code 68760 reports the surgical closure of a section of the canalicular and lacrimal system that includes the lacrimal punctum. A heat source is used to seal the punctum. Code 68761 reports a punctum closure using either a permanent silicone plug or a temporary collagen plug. Medicine Codes Ophthalmology Services described by ophthalmology medicine codes include general services (medical examination and evaluation), special services, ophthalmoscopy, electroretinography, contact lens services, prescription, and fitting of ocular prosthesis, spectacle services, and the supply of materials. General Ophthalmological Services (92002-92014) These CPT® codes are specific to the typical services rendered during an ophthalmological visit. The CPT® codes used for the reporting of general ophthalmological services are based on new and established patient criteria and level of service provided. For supply of spectacles, use the appropriate supply codes in the HCPCS Level Il code set. To determine what level of service to code, you and the provider must be familiar with the terms intermediate and comprehensive as they apply to ophthalmological services. Intermediate ophthalmological services include an evaluation of a new or existing condition complicated by a new diagnostic or management problem (not necessarily related to the primary diagnosis), including a history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as indicated. According to CPT®, this service “may include the use of mydriasis for ophthalmoscopy.” Mydriasis is the increase in pupil size that normally occurs in the dark or artificially using drugs. A mydriatic agent to dilate the pupils facilitates visualization of the ocular media and fundus. Comprehensive ophthalmological services include an evaluation of the complete visual system. This service may require more than one visit. The service includes a history; general medical observation; external examination (examination of the eye and adnexa [following the eyelids, lashes, eyebrows, alignment of the eye, and motility of the eye, conjunctiva, cornea, and iris]); ophthalmoscopic examination of the ocular media, the retina, and optic nerve, gross visual fields; and a basic sensorimotor examination. Refer to the cPT® Ophthalmology subsection guidelines for definitions and examples for intermediate and comprehensive ophthalmological services. Intermediate Comprehensive History History General medical observation General medical observation External ocular and adnexal exam External and ophthalmoscopic exam Other diagnostic procedures as indicated Gross visual fields May include mydriasis Basic sensorimotor exam Biomicroscopy and tonometry for an acute complicated condition (e.g., iritis) or established patient with | Often includes biomicroscopy, exam with cycloplegia or mydriasis and known cataract tonometry. Always includes initiation of diagnostic and treatment programs 17
Chapter 15: Eye and Ocular Adnexa, Auditory Systems Special Ophthalmological Services (92015-92287) A special evaluation of part of the visual system is made that goes beyond the services included under general services. These special ophthalmological services may be reported in addition to a general ophthalmological services or E/M services. Interpretation and report by the physician are an integral part of special ophthalmological services where indicated. Technical procedures are often part of the service but should not be mistaken to constitute the service itself. Fluorescein angioscopy and quantitative visual field examination can be reported separately, when performed. PRACTICAL CODING NOTE When only one eye is assessed, use modifier 52 to report reduced services. Modifier 50 should not be used with CPT® codes 92002-92066 and 92081-92100. These codes constitute integrated services in which medical decision-making cannot be separated from the examining techniques. Itemization of service components, such as a slit lamp examination, keratometry or retinoscopy, is not applicable. A gonioscope is used to examine the trabecular meshwork, located at the angle of the eye where the iris and cornea meet. A special contact lens (a goniolens) is placed on the cornea to eliminate the curvature of the comea, allowing light to be reflected into the angle of the anterior chamber. This procedure is considered noninvasive and helps to locate foreign bodies in the anterior chamber, to evaluate tumors, cysts, and trauma or to view anatomic structures behind the iris. Codes 92081-92083 report visual field examination, unilateral or bilateral. Measurements are taken of space visible to an eye fixated straight ahead. Level of service is dependent upon degree of field measured, point of field, and thresholds. The CPT* guidelines note that basic confrontational fields are a part of all eye exams. CPT® code 92100 reports serial tonometry. Serial tonometry is a measurement of the outflow of aqueous from the eye and it determines if the fluids in the eye are at proper levels and circulating properly. When this service is performed, a serial tonometry monitors the pressure over a long period to look for a time of day rhythm (a number of measurements separated by many hours). Ophthalmoscopy (92201-92260) Ophthalmoscopy, is an examination used primarily to examine the fundus or posterior portion of the interior of the eye. The anterior portion of the eye, composed of the cornea, iris, and lens is also examined in the course of focusing on the interior of the eye. Indirect ophthalmoscopy is most commonly used by retinal surgeons for preoperative diagnostic evaluation and during surgery for repair of retinal detachment. Fluorescein angiography involves laser scanning for reconstructing images for display on a cathode ray tube. This procedure helps to evaluate the surface of the eye for disease or injury. Fluorescein dye is a dye that emits light when a specific light is used to enhance the imaging during fluorescein angiography. Several abnormalities may be identified in this process such as microscopic aneurysms, arteriovenous shunts, and neovascularization. Report CPT® code 92235 for fluorescein angiography that includes multiframe imaging, interpretation, and report unilateral or bilateral. Multiframe imaging involves multiple, rapid photographs taken approximately one second apart. The procedure includes interpretation and report. This code is for a unilateral or bilateral service. Indocyanine green angiography (92240) is a diagnostic study in which retinal and choroidal inclusions are displayed and photographed utilizing computer technology. It can be used in conjunction with a fluorescein angiography study if the fluorescein does not provide enough diagnostic information. When fluorescein and indocyanine-green angiography are performed at the same patient encounter, use 92242, If performed on the same day, but not the same session, code 92235 and 92240. A written report or medical documentation should accompany insurance claims when this occurs. Ophthalmodynamometry (92260) is a procedure used to obtain an approximate measurement of the pressure in the central retinal arteries. It measures indirectly the flow of blood in the carotid artery on each side of the body. This procedure is often performed on patients who are blacking out in one eye or experiencing periodic attacks of weakness, etc. This is a bilateral procedure and if performed on only one eye, report the reduced service modifier 52. Contact Lens Services (92310-92326) Prescription of contact lens is not a part of general ophthalmological services. The fitting of lens includes patient instruction, training, and incidental revision, as necessary. CPT® codes 92310-92317 report the prescription and medical supervision for the fitting of corneal contact lenses. CPT* codes 92310 and 92314 describe services to both eyes except for aphakia. Append modifier 52 if the prescription and fitting of a contact lens is for only one eye. CPT® states that the supply of contact lenses may be reported as part of the service of fitting or it may be reported with appropriate supply codes. Spectacle Services (Including Prosthesis for Aphakia) (92340-92371) Fitting of spectacles may be reported separately with the appropriate CPT* code from this subsection. This service includes measurement of anatomical facial characteristics, writing of laboratory specifications, and final adjustment of the spectacles to the visual axes and anatomical tomography. The prescription of spectacles, when required, is an integral part of the general services. Auditory System Understanding anatomy of the ear is essential to procedural coding. Procedures are organized anatomically: external, middle, and inner ear. External Ear (69000-69399) Many of the external ear procedures are simple procedures that can be performed by any practitioner; for example, 69200 Removal foreign body from external auditory canal; without general anesthesia. This is a popular code among pediatricians. Repair codes in the External Ear subheading are often performed by plastic surgeons and relate to plastic defects that may be congenital or due to injury. Incision Perichondpritis is an infection of the perichondrium of the pinna. Perichondritis may be initiated by trauma, insect bites, incisions, or superficial infections of the pinna, in which pus accumulates between the cartilage and the perichondrium. The blood supply to the cartilage is provided by the perichondrium. If the perichondrium is separated from both sides of the cartilage, the resulting avascular necrosis leads to a deformed pinna. Septic necrosis also plays a role. Perichondritis tends to be indolent, long lasting, and destructive. Gram- negative bacteria usually cause perichondritis. The provider may perform an incision and drainage by means of suction to the external ear to approximate the blood supply to the cartilage. Code 69000 reports simple drainage of the external ear for abscess or hematoma. Code 69005 reports a more complex external ear drainage procedure for an abscess or hematoma. The complicated procedure requires additional time to clean the abscess cavity and usually includes insertion of a small drain tube or packing of the abscess with the application of antibiotic eardrops. 18
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems Excision Basal cell and squamous cell carcinomas frequently develop on the pinna after regular exposure to the sun. Early lesions can be successfully treated with cautery and curettage or radiation therapy. More advanced lesions affecting the cartilage require surgical excision of V-shaped wedges or of larger portions of the pinna. If an entire lesion is removed from the external ear with a simple repair, report code 69110. Code 69120 reports a complete amputation of the external ear. Excision exostosis(es), external auditory canal refers to the removal of a benign bony growth from the ear canal. To remove an exostosis, the surgeon makes an incision through the skin above the exostosis to expose the bone beneath it. The bony growth is chipped away with a chisel or drill. Code 69140 reports the excision of an exostosis or exostoses of the external auditory canal. Removal Removal of a foreign body from the inside of the ear canal is reported with code 69200 without general anesthesia or 69205 with general anesthesia. Modifier 50 (or LT and RT, depending on the payer) is appended to these codes if both ears are involved. Cerumen refers to ear wax. When impacted cerumen is removed by irrigation or lavage, report 69209. When impacted cerumen is removed from the ear by instrumentation, such as cerumen spoon, vacuum evacuation, or forceps, report code 69210. Use modifier 50 (or LT and RT, depending on the payer) if the procedure is performed bilaterally. When cerumen is not stated to be impacted, report an E/M code. CPT® code 69220 describes routine cleaning performed every three to six months to remove skin debris and drainage from the mastoid cavity after a radical or modified radical mastoidectomy. Code 69222 reports when the cleaning is more extensive, such as when an infection is present, or anesthesia is required. Simple procedures are generally performed in the office, while complex procedures are generally performed in the operating room. Repair Oroplasty (69300) is a surgical procedure (cosmetic) performed to correct protruding ear(s). When a surgeon performs an otoplasty, an incision is made on the posterior auricle. A new antihelical fold is created. The cartilage and ear size may also be reduced. Moderate sedation is reported separately if performed. A common diagnosis in a medical record may include macrotia, bat ear, Stahl’s ear, or other types of congenital anomalies of the ear. Code 69320 reports when the surgeon performs a single-stage reconstruction of the external auditory (canal) for congenital atresia. Reconstruction of the external auditory canal corrects congenital malformations when no middle ear reconstruction is necessary. If this procedure is performed bilaterally, append modifier 50. Some payers require two line items showing the CPT® code with the modifier appended to the second line item, while others require the procedural code with modifier 50 as a single line item. d R Middlle oar Outer ear Ineves ear nous Ossicular chain 7 Temponl . mincle Fat | Semacincouiar A Stapes Scapha \ o B - . Trisngular fossa —F o . o Anthelx - " B> ‘. Aunicie LRI (o pinna) 1 1 Concha v 1‘ lA _..‘ ’ o \ Earlobe PEBINEEL, o vwcn mpora rternal membesne \ Ta J E Cartilage "fl'r'::' (marchrum) Tympanic bone cavity ar | ’ Middle Ear (69420-69799) The middle ear includes the tympanic membrane (eardrum), the auditory ossicles, and four openings. The auditory ossicles consist of three small bones commonly known as the hammer, anvil, and stirrup. These three bones are medically known as the malleus, incus, and stapes, respectively. These middle ear bones are linked to allow the transmission of sound waves. The middle ear cavity is air-filled and has four openings. The footplate (forming the base of the stapes) sits over the oval window that covers the vestibule of the inner ear. The round window opens into the cochlea of the inner ear. The Fustachian tube has an opening that leads to the upper part of the throat behind the nose. The aditus is an inlet that leads to the mastoid cavity, or sinus, behind the middle ear. The Eustachian tube opens on the front wall of the middle ear and extends to the pharynx. The Eustachian tubes are 3-4 cm long and are lined with a mucous membrane. These tubes permit equalization of air pressure between the internal ear and the outside of the body. Occlusion of the Fustachian tube leads to the development of otitis media. Most procedures on the Eustachian tubes are performed in the physician’s office. Incision A myringotomy is the surgical incision of the tympanic membrane to relieve pressure and release pus from an infection. In this procedure, fluid is gently suctioned out of the middle ear. This surgical procedure is also known as a tympanotomy or myringostomy. When a surgeon performs Eustachian tube inflation, a catheter is inserted via nasal cavity with the aid of a nasopharyngoscope. Air is forced into the catheter to inflate the Eustachian tube and the catheter is removed. This procedure is performed when a patient is diagnosed with chronic serous otitis media, a permanent perforation of the tympanic membrane with or without permanent changes in the middle ear, and to relieve the pain. Tympanostomy Tympanic refers to procedures of the middle ear. The tympanic cavity is the main cavity of the ear between the eardrum and the inner ear. The tympanum, or myringa, is the membrane in the ear that vibrates to sound. A tympanostomy involves the surgical insertion of ventilation tubes, also called pressure equalization (PE) or tympanostomy tubes, into the eardrum, where they remain to allow for continual drainage of fluid and normalization of pressure in the ear space. 19
Chapter 15: Eye and Ocular Adnexa, Auditory Systems Bilateral tympanostomies (myringotomies) with the insertion of ventilation tubes is one of the most common surgical procedures performed in the United States today for children with recurrent otitis media. Code 69436 reports a tympanostomy requiring insertion of a ventilating tube. To report a bilateral tympanostomy with ventilation tube insertion, use modifier 50. Mastoidectomy The mastoid bone is a bone located behind the ear (felt as a hard bump behind the ear). The air cells inside are connected to the middle ear through an air-filled cavity called the mastoid antrum. Mastoidectomy is a surgical procedure designed to remove infection or growths in the mastoid bone. Access to the middle ear, antrum, and mastoid for chronic ear disease and cholesteatoma is performed by drilling away bone to visualize these areas, rid the disease, and reconstruct the conductive hearing mechanism. A cholesteatoma is a sac that expands by collection of cells and debris. Depending on the amount of infection or cholesteatoma present, various degrees of mastoidectomies can be performed. In a simple mastoidectomy (69501), the surgeon opens the bone and removes any infection. A tube may be placed in the eardrum to drain any pus or secretions present in the middle ear. Antibiotics are then given intravenously (through a vein) or by mouth. A modified radical mastoidectomy (69505) involves a postaural or endaural incision and a posterior tympanomeatal flap is reflected forward drill out the mastoid cortex. Granulations and cholesteatoma are removed. The posterior bony canal wall is removed to the level of the facial nerve and ossicles are removed if involved in the cholesteatoma. The posterior skin flap and eardrum are repositioned and a meatoplasty is performed. Both a modified radical and a radical mastoidectomy usually result in less than normal hearing. A radical mastoidectomy (6951 1) removes the most bone and is indicated for extensive spread of cholesteatoma. The posterior and superior bony canal walls are taken down. The Eustachian tube orifice mucosa, middle ear mucosa, granulations, and cholesteatoma are removed. The eardrum and middle ear structures may be completely removed. Usually the stapes (the stirrup-shaped bone) is spared, if possible, to help preserve some hearing. Repair A tympanoplasty (codes 6963 1-69646) is a surgical procedure that involves repairing or reconstructing the eardrum. In a tympanoplasty without mastoidectomy (69631), the middle ear is explored. If adhesions or squamous debris is located, the surgeon removes them and palpates the ossicles. Tympanoplasty may involve one or more of the following procedures: 1. A canaloplasty is the repair of the external ear canal usually due to trauma, especially basilar skull fracture trauma. 2. An atticotomy is the cutting of an opening in the wall of the attic, which is the cavity of the middle ear that lies above the tympanic cavity and contains the upper portion of the malleus and most of the incus. 3. Ossicular chain reconstruction involves the repair of the three small bones in the ear called ossicles. The three small bones are the malleus, incus, and stapes. These bones may be replaced with prosthetic bones. This procedure is usually performed for chronic ear infection, trauma, or perforation of the eardrum. Inner Ear (69801-69949) The inner ear consists of a bony labyrinth within the temporal bone lying on either side of the head. This complex structure has three parts: the semicircular canals, the vestibule, and the cochlea. The three semicircular canals maintain equilibrium and merge into the vestibule, which contains fluid. The oval window, in the middle ear, covers the vestibule, which contains perilymph fluid. Incision and/or Destruction A patient diagnosed with active Méniére's disease (e.g., cochleovestibular or vestibular) may undergo a procedure called a labyrinthotomy. Code 69801 reports labyrinthotomy with perfusion of vestibuloactive drug(s) via transcanal approach. A small catheter or needle is inserted into the middle ear for the administration of drugs such as aminoglycosides, corticosteroids, antibiotics, or local anesthetics. Vertigo may be caused by acute labyrinthitis (a viral inflammation of the inner ear), benign positional vertigo (a condition due to abnormally floating crystals in the inner ear that stimulate the nerve endings of the inner ear), delayed symptom of head injury, or result of cervical spine problems. Procedures to decrease the severity of symptoms include endolymphatic sac decompression (69805), which involves making an incision behind the involved ear and exposing the mastoid bone. The mastoid cavity is drilled out until the endolymphatic sac is exposed and opened. The posterior ear canal wall remains intact. If a shunt is inserted into the sac to allow for future drainage, report 69806. Excision In individuals with complete or near complete hearing loss in one ear due to Méniere's, a surgical procedure termed a labyrinthectomy (69905-69910) may be performed. An incision is made in the posterior canal skin and the skin flap and posterior eardrum are reflected forward. Under microscopic visualization, the incus and stapes are removed. A right-angle hook is fed through the oval window to remove the contents of the vestibule. The surgeon may drill a connection between the oval and round window. The middle ear is packed, and the eardrum and canal skin are repositioned, and the ear canal is packed. This procedure may be performed with a mastoidectomy (69910). A vestibular nerve section is performed when a patient is diagnosed with acute mastoiditis accompanied with other complications or vestibular neuronitis (a benign disorder characterized by sudden onset of severe vertigo that can last seven to 10 days). In a vestibular nerve section, using a translabyrinth approach, the surgeon drills out the mastoid cavity, removes the semicircular canals, and then removes the bone over the internal auditory canal. The dura is opened, and the vestibular nerve is cut. The dura is closed, and the mastoid cavity is packed. Code 69915 reports a vestibular nerve section by translabyrinth approach. For a transcranial approach, report 69950. A cochlear implant is an electronic device that is implanted under the skin and is used to treat sensory deafness. Electrodes in the middle ear assist in the creation of sound sensation for a patient who has this device implanted. The first cochlear implant procedure was performed in 1978 in Australia. Code 69930 reports cochlear device implantation, with or without a mastoidectomy. Temporal Bone, Middle Fossa Approach This subheading describes the middle fossa approach to the temporal bone and includes primary procedures and an unlisted code for other procedures. The temporal bones form the sides and part of the base of the skull. They are among the hardest of all bones and enclose the organs of the hearing and balance systems. The middle fossa approach provides surgical access to lesions of the geniculate ganglion and the labyrinthine portion of the facial nerve as well as to the internal acoustic canal and helps preserve cochlear function. Bell's palsy is a unilateral facial paralysis resulting from dysfunction of the facial nerve (cranial nerve VII). If no specific cause such as brain tumor or stroke is identified, the condition is known as Bell's palsy. A patient diagnosed with Bell's palsy shows symptoms of weakness to an entire half of the face. The extent of nerve damage determines patient outcome. A total nerve decompression and repair are common surgical procedures to repair facial nerve damage. Several approaches are used via temporal bone, mastoid approach, or through the external auditory canal. If the nerve has been transected because of trauma, it can be repaired with sutures. Code 69955 reports a total facial nerve decompression and/or repair. This code includes a graft. Code 69970 reports when the surgeon, through a middle cranial fossa approach, removes a temporal bone tumor. 20
Chapter 15: Eye and Ocular Adnexa, Auditory Systems The Medicine Section — Special Otorhinolaryngologic Services (92502-92700) CPT® codes described in the Special Otorhinolaryngologic subsection of CPT® describe diagnostic and treatment services not included in E/M services (99202-99215, 99242-99245). Aural rehabilitation is auditory training or therapy provided by the physician or the clinically trained staff member. It includes speech, language, and hearing loss, and physical and mental development. Once an assessment is made, the physician provides the patient with a plan that may involve speech therapy or hearing aids, etc. Code 92512 reports nasal function studies (for example, rhinomanometry). This study is used to evaluate the normal and abnormal function of the nose. The rhinomanometer measures the flow and pressure of air through the nose to assess the degree of obstruction, if any. This test can be performed by anterior or posterior measurements. Vestibular Function Tests (92531-92549) Vestibular function tests evaluate conditions such as vertigo (92531-92534). Vertigo is an abnormal sensation of rotary movement associated with difficulty in balance, gait, and navigation of the environment. Lesions (disturbances in the inner ear), in the eighth cranial nerve or vestibular nuclei and their pathways in the brainstem and cerebellum can cause vertigo. Often the physician will perform clinical evaluations of the vestibular apparatus. Evaluation by the physician includes tests such as rapidly alternating movement {for example, finger-to-finger, heel-to-shin test, gait testing). Other vestibular function tests begin by artificial stimulation of the vestibular apparatus to produce nystagmus. Nystagmus is the involuntary rhythmic oscillation of the eyeball and could be a clinical manifestation of diseases such as multiple sclerosis or an Amold-Chiari malformation (downward displacement of the cerebellar tonsils through the foramen magnum, the opening at the base of the skull). Nystagmus is the most useful response that can be monitored by clinician observation or more reliably, by electronystagmography. CPT® codes for the evaluation of nystagmus include 92531 for spontaneous nystagmus including gaze, and code 92532 for positional nystagmus. When these procedures are performed with recording, codes 92541 and 92542 are reported. Nystagmus is the rapid, involuntary rhythmic movement of the eye. Optokinetic nystagmus test (92534) induces nystagmus by having the patient look at objects moving across the visual field. Caloric vestibular tests (92537, 92538) are performed to validate a diagnosis of asymmetric function in the peripheral vestibular system. Audiologic Function Tests (92550-92596) A physician or audiology technician may perform an audiologic function test to diagnose the cause of hearing loss. The audiometric testing listed implies the use of calibrated electronic equipment. When assigning these codes, you and the physician are indicating that the services were performed on both ears. Use modifier 52 if the testing is on one ear. When a physician or audiology technician performs a screening test for pure tones, air only, the patient responds to different pitches and intensities of tones. If the patient fails to respond appropriately, additional testing is recommended. Speech audiometry (92555, 92556) is a valuable clinical measurement of hearing. This type of audiometry tests the ability of the patient to discriminate various speech sounds. A visual reinforcement audiometry (VRA) test (92579) is usually performed on infants and difficult-to-test children and adults. This testing addresses the type and severity of hearing loss. The service includes a history and otologic exam (conducted in a sound booth). Lighted toys are used for children as reinforcement for response to auditory stimuli. Codes for testing evoked otoacoustic emissions (92587, 92588) report a noninvasive audiologic function test used to identify hearing defects in newborns and young children. The physician places a probe tip in the ear canal. This probe emits a clicking sound that passes through the tympanic membrane, middle ear, and then to the inner ear where the sound is identified by cochlear hair cells. The computer records the echo transmitted from the hair cells. Evaluative and Therapeutic Services (92601-92633) Codes 92601-92604 report the diagnostic analysis of cochlear implants for patients in two age ranges (under seven years of age in codes 92601 and 92602; and age seven years and up in codes 92603 and 92604). Codes 92610 and 92611 report evaluation of oral and pharyngeal swallowing function and motion fluoroscopic evaluation of swallowing function by cine or video recording, respectively. Code 92597 reports an evaluation for the use and/or fitting of a voice prosthetic device to supplement oral speech. Speech generating devices (SGD) are speech aids that provide functional speaking abilities to individuals with severe speech impairment. Digitized speech, sometimes referred to as devices with whole message speech output, utilize words or phrases that have been recorded by an individual other than the SGD user for playback upon command of the SGD user. Synthesized speech translates a user’s input into device-generated speech using algorithms representing linguistic rules. Users of synthesized speech SGDs are not limited to prerecorded messages and they can independently create messages as their communication needs dictate. A flexible endoscope is used in codes 92612-92617 to evaluate swallowing by cine or video recording and to report laryngeal sensory testing by cine or video recording. The codes include technical and professional components. Flexible endoscopic evaluation of swallowing with sensory testing provides an assessment of hypopharyngeal sensitivity, which gives clinicians information regarding a patient’s ability to protect the airway during the ingestion of food and provides evidence regarding the patient’s control of secretions. A patient’s laryngopharyngeal sensory capacity can be tested using endoscopically administered air pulse stimuli to the mucosa of the larynx innervated by the superior laryngeal nerve. Two codes describe central auditory function testing services using both speech and nonspeech stimuli to allow reporting multiple individual tests performed during a clinical visit. Code 92620 reports the initial 60 minutes of tests performed and code 92621 reports each additional 15-minute increment. The time may be spent in evaluation with a single test performed repeatedly or for a battery of multiple tests performed during a single encounter. These codes may not be reported in conjunction with 92521, 92522, 92523, or 92524. To report evaluation of speech fluency, speech sound production and evaluation of language comprehension and expression assign 92521, 92522, 92523, or 92524 as appropriate. Codes 92507 and 92508 report the treatment of speech, language, voice, communication, and/or auditory processing disorders; code 92507 reports individual treatment; and code 92508 reports group treatment. Code 92625 reports tinnitus assessment to include pitch, loudness matching, and masking. 21
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4 % Chapter 15: Eye and Ocular Adnexa, Auditory Systems 1. Section Review 15.3 2. The patient is complaining of severe corneal pain and believes a wood chip entered his eye. He was working in his woodworking shop without goggles this morning. After placing two drops of proparacaine 0.5% in the right eye, | administered fluorescein and examined the cornea under ultraviolet light using a slit lamp. Seidel sign negative for penetrating injury. A small piece of wood was identified under a flap of lamellar cornea, and | was able to dislodge the wood and flush it from the eye. A single suture was placed to secure the flap. What CPT® code is reported for this procedure? A. 65270 B. 65275 C. 65280 D. 65285 Answer: B. 65275 Rationale: The presence of the foreign body has no bearing on code selection. In the CPT* Index, see Cornea/Repair/Wound/Nonperforating 65275. Note the code reads with or without removal of foreign body. The key to code choice is the site of the injury, which is the cornea and it was a nonperforating injury (lamellar means partial thickness of the cornea). The topical anesthetic is bundled into the procedure, although the physician could bill separately for any IV sedation used or if a therapeutic contact lens was applied. The 55-year-old patient presents with 1 cm lesion in his right ear canal posterior to the tragus. The lesion is red and raised, typical of basal cell carcinoma. After administration of lidocaine, | performed a shave biopsy. Electrocautery was required to control bleeding. The tissue sample was sent to pathology. What CPT® code is reported for this procedure? A. 69100 B. 69105 C. 11301 D. 11102 Answer: B. 69105 Rationale: Although the area biopsied is skin, a code from the Auditory System chapter of CPT*® is appropriate for this biopsy. CPT* tells us to report code 69100 for a biopsy of the external ear, and 69105 for a biopsy of the external auditory canal. In the CPT* Index, look for Biopsy/Auditory Canal, External. The tragus is the protective cartilage knob anterior to the ear canal. Code 69105 is the correct code for a biopsy, by any method of the external auditory canal. Today we excised bilateral recurrent pterygium under topical anesthetic. The conjunctival incisions were repaired simply. What CPT® code is reported for this procedure? A. 65420-50 B. 65426-50 C. 6811050 D. 68115-50 Answer: A. 65420-50 Rationale: In the CPT* Index, look for Pterygium/Excision 65420. A pterygium is an overgrowth of conjunctiva forming in the nasal aspect of the eye and growing outward towards the cornea. Excision of a pterygium is reported separately from other conjunctival disorders, with codes 65420 and 65426. Because this was a simple repair without a graft, 65420 is the correct code. Modifier 50 indicates a bilateral procedure was performed. The patient underwent a plastic repair of the external auditory canal for stenosis, a late effect of a burn. After excising the subepithelial stenotic tissue and a wedge of skin is reported for this procedure? from the floor of the external auditory canal, a rubber tube was placed inside the external canal. The patient will return in two weeks to monitor his progress. What CPT* code A. 69433 B. 69799 C. 69310 D. 69140 Hide Answer » Answer: C. 69310 Rationale: In the CPT* Index, look for Meatoplasty/External Auditory Canal 69310. The external opening of the ear is referred to as the meatus. A meatoplasty enlarges the opening. Another index option is to look for Auditory Canal/External/Reconstruction/for Stenosis 69310. 22
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9. 8. Chapter 15: Eye and Ocular Adnexa, Auditory Systems 5. 6. 7 The patient has hypertropia in her right eye with prior eye operations in this eye and today we are performing a recession of the superior oblique muscle to balance this muscle and eliminate strabismus. Adjustable sutures are applied. She is pseudophakic. What CPT*® codes are reported for this procedure? A. 67318,67335-51 B. 67314,67335, 67331 C. 67318,67331,67335 D. 67314, 67335, 67320 Answer: C. 67318, 67331, 67335 Rationale: In the CPT* Index, look for Strabismus/Repair/Superior Oblique Muscle 67318. Code 67318 is the only code listed describing a procedure on the superior oblique muscle. In addition to 67318, report add-on codes for adjustable sutures. In the index, see Strabismus/Repair/Adjustable Sutures 67335. This patient has a history of ophthalmic surgery. The medical history of ocular surgery makes the procedure riskier and more difficult. Look in the index for Strabismus/Repair/Previous Surgery, Not Involving Extraocular Muscles 67331. Modifier 51 is never applied to add-on codes. A patient with severe mixed hearing loss from chronic otitis media undergoes a round window implant with floating mass transducer. What CPT® code is reported for this procedure? A. 69799 B. 69667 C. 69714 D. 69710 Answer: A. 69799 Rationale: In the CPT® Index, look for Ear/Unlisted Services and Procedures. The correct answer is A, for an unlisted procedure. Round window implants are a new technology not yet assigned CPT* a code. The word transducer should alert you to the hearing aid component of this procedure. There isn't a new technology Category 111 code for this type of procedure, so an unlisted code is the best choice. The round window is the barrier between the middle and inner ear, but it is still considered middile ear. A patient has an oversized and embedded dacryolith in the lacrimal sac, and a dacryocystectomy is performed. What CPT® code(s) is/are reported for this procedure? A. 68500 B. 68420 C. 68520 D. 68520,68420-51 Hide Answer Answer: C. 68520 Rationale: In the CPT® Index, look for Dacryocystectomy referring you to 68520. The stone was embedded in the sac, which was removed. Only one code is used for removal of the stone and removal of the sac. The lacrimal gland is located near the eyebrow; the lacrimal sac is the upper dilated end of the lacrimal duct, aligned with the nostril. A patient underwent mastoidotomy for ossicular chain reconstruction with tympanic membrane repair, atticotomy, and partial ossicular replacement prosthesis. What CPT® code is reported for this procedure? A. 69632 B. 69635 C. 69636 D. 69637 Answer: D. 69637 Rationale: In the CPT® Index, look for Mastoidotomy. Code 69637 represents a mastoidotomy (including atticotomy and tympanic membrane repair) with ossicular chain reconstruction and partial ossicular replacement prosthesis. B C D What CPT® code is used to report surgery to remove an aqueous shunt from the patient’s extraocular posterior segment of the eye? A. 65265 65920 67120 67121 Hide Answer » Answer: C. 67120 Rationale: An aqueous shunt is implanted material in the extraocular posterior segment of the eye. In the CPT* Index, look for Eye/Removal/Implant/Posterior Segment referring you to 67120-67121. It can also be found by looking for Removal/Implant/Eye. 23
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems 10. An ophthalmologist sees a patient for a yearly eye exam under his vision benefits and follow up for a cataract diagnosed at the last visit. The exam includes a history, external examination, ophthalmoscopy, biomicroscopy, and tonometry. The cataract of the left eye is stable and there are no new findings. The patient will return in one year. What CPT® code is reported for this procedure? A. 92004 B. 92002 C. 92012 D. 92014 Hide Answer a Answer: C. 92012 Rationale: In the CPT" Index, look for Ophthalmology, Diagnostic/Eye Exam/Established Patient referring you to 92012-92014. The cataract is stable and there were no other findings resulting in an intermediate exam. A comprehensive ophthalmological service always includes initiation of diagnostic and treatment programs. HCPCS Level | HCPCS Level Il codes report the supply of injectable or implantable drugs used in the treatment of ear and eye disorders, as well as supply of prostheses, visual aids, contact lenses, glasses, and hearing aids. Glaucoma screening codes for ophthalmologists or optometrists participating in the Physician Quality Reporting System (PQRS) are reported with temporary G codes (G0117 and GO118). Many of the prosthetics and durable medical equipment (DME) reported through HCPCS Level 1 are no longer distributed by physicians. Instead, they write prescriptions for these items. The most important codes to consider as you study the HCPCS Level Il codes for ophthalmic and ENT procedures are the supply of drugs for injections. The Table of Drugs and Biologicals in your HCPCS Level I code book will list these alphabetically, so they are easy to locate. Always confirm your code choice in the numeric list of your HCPCS Level Il code book. Modifiers Eye and ear specialists use many of the same modifiers as other physicians. There are some modifiers, however, that take on significant importance for them. Because the eyes and ears are bilateral organs, identifying a procedure as bilateral (50) or identifying laterality (RT and LT) becomes very important to the payment process. Insurance typically doesn’t cover the removal of a cataract more than once per eye; if the payer does not know which eye was treated, it will not know which one is left to treat. Another issue for payers is whether the patient has his own lens (phakic); an artificial lens (pseudophakic); or no lens (aphakic). Aphakic patients may be eligible for benefits not available to others. 50 Bilateral procedure E1 Upper left eyelid E2 Lower left eyelid E3 Upper right eyelid E4 lLower right eyelid LS FDA—monitored 0L implant LT Left PL Progressive addition lenses RT Right 24
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems DOCUMENTATION DISSECTION CASE1 Preoperative Diagnosis: Left lower eyelid basal cell carcinoma Postoperative Diagnosis: Same Operation: Excision of left lower eyelid basal cell carcinoma with flaps and full thickness skin graft and tarsorrhaphy. Indication for Surgery: The patient is a very pleasant female who complains of a one-year history of a left lower eyelid lesion and this was recently biopsied and found to be basal cell carcinoma. She was advised that she would benefit from a complete excision of the left lower eyelid lesion. She is aware of the risks of residual tumor, infection, bleeding, scarring and possible need for further surgery. All questions have been answered prior to the day of surgery. She consents to the surgery. Operative Procedure: The patient was placed on the operating room table in the supine position and an intravenous line was established by hospital staff prior to sedation and analgesia. Throughout the entire case the patient received monitored anesthesia care. The patient’s entire face was prepped and draped in the usual sterile fashion with a Betadine solution and topical tetracaine and corneal protective shields were placed over both corneas. A surgical marking pen was used to mark the tumor. 3 mm markings were obtained around the tumor. & Tumor was noted to encompass approximately one-third of the left lower eyelid. & A wedge resection was performed, and this was marked and 2% Xylocaine with 1:100,000 epinephrine, 0.5% Marcaine with 1:100,000 epinephrine was infiltrated around the lesion. This was excised with a £15 blade. This was sent for intraoperative fresh frozen sections. Intraoperative fresh frozen sections revealed persistent basal cell carcinoma at the medial margin. Another 2 mm of margin El was discarded and a revised left lower eyelid medial margin was sent for permanent sections. The area could not be closed primarily, thus a tarsoconjunctival advancement flap was advanced from the left upper eyelid to fill the defect. ™ This was sutured in place with multiple 5-0 Vicryl sutures. The anterior lamella defect of skin was closed by harvesting a full-thickness skin graft from the left upper eyelid and placing it in the left lower eyelid defect. = This was sutured in place with multiple interrupted 5-0 chromic gut sutures. The eyelids were sutured shut both on the medial aspect of the Hughes flap as well as the lateral aspect of the Hughes flap with a 4-0 silk suture. ™ A pressure dressing and TobraDex ointment were applied. The patient tolerated the procedure well and was transported back to the recovery area in excellent condition. 1 3 mm margin is excised in addition to the lesion. El The size of the lesion is one-third of the left lower eyelid. =l An additional 2 mm is excised. Bl A flap is used to close the defect. El A FTSK from the upper eyelid is used to repair the defect of the lower eyelid. & A tarsorrhaphy is performed. What are the CPT* and ICD-10-CM codes reported? CPT® codes: 15260-E2, 67966-51-F2, 67971-51-F2, 67875-51-E1-F2 ICD-10-CM code: C44.1192 Rationale: An excision of a basal cell carcinoma is performed. More than one-third of the lower eyelid is excised. A full thickness graft, as well as a flap (adjacent tissue transfer), is required for the closures. From the CPT* Index, look up Excision/Lesion/Eyelid. Refer to the codes referenced in the Index. Under code 67840, there is a parenthetical note that states, “For excision and repair of eyelid by reconstructive surgery, see 67961, 67966." Code 67961 is an excision and repair of the eyelid including preparation for skin graft or flap with adjacent tissue transfer or rearrangement involving up to one-fourth of the lid margin. In this case the excision is larger. Code 67966 reports the excision and reconstruction with a flap or an excision over one-fourth of the lid margin, which is one of the correct codes for this case. From the CPT® Index, look up Reconstruction/Eyelid/Tarsoconjunctival Flap Transfer 67971. Also performed is a full-thickness skin graft from the left upper eyelid, which was placed on the left lower eyelid defect. Skin grafts are always reported according to the recipient site. Look in the CPT*® Index for Skin Graft and Flap/Free Skin Graft/Full Thickness 15200-15261. The size is not reported, so 15260 is assigned. A tarsorrhaphy (eyelids sewn shut) is performed. Look in the CPT® Index for Tarsorrhaphy 67875. Review the code descriptions for accuracy. Code 67875 is reported with HCPCS modifiers E1 and E2 because both eyelids were closed shut. When multiple procedures are performed, they are sequenced in order from the most labor intensive (highest RVUs) to the lowest. In this case, the proper sequence is 15260, 67966, 67971, and 67875. The procedures are performed on the left lower eyelid, which is reported with modifier E2. When multiple procedures are performed, modifier 51 is appended to the procedure codes (except for add-on codes and modifier 51 exempt codes) listed after the first-listed CPT® code. To determine the diagnosis code, look in the ICD-10-CM Alphabetic Index for Carcinoma/basal cell You are directed to see Neoplasm, skin, malignant. Look in the Table of Neoplasms for Neoplasm, neoplastic/skin/eyelid/basal cell carcinoma and use the code from the Malignant column, C44.11-. The 6™ character 9 specifies the left eyelid, the 7" character 2 specifies the lower eyelid. 25
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems CASE 2 Preoperative Diagnosis: Chronic otitis media with effusion Postoperative Diagnosis: Chronic otitis media with effusion Procedures Performed: Bilateral tympanoplasty tube insertion, removal of previous placed right tube Indications: The 23-month-old child status post tubes one year ago. The tubes have extruded, and his problem has returned. Therefore, the above procedure was planned. Prior to the procedure, all the risks vs. benefits were discussed at length with the patient’s mother. An informed consent was obtained. Findings: Dull membranes bilaterally with serous fluid. Procedure in Detail: After appropriate written consent was obtained from the patient’s parents, he was taken to the operating room, placed supine on the operating stretcher. General anesthesia ! was given by mask. Once an adequate depth of anesthesia had been achieved, the right ear was examined with an operating microscope. 2 The tympanic membrane was noted to be retracted and dull. A tube was noted in the external auditory canal which was removed with alligator forceps. © A small radial incision was made on the tympanic membrane ¥ and the serous fluid was suctioned from the middle ear. A Paparella style tube was placed. Saline drips were applied. Attention was then turned to the left ear. ® Again, the tympanic membrane was noted to be retracted and dull. A small radial incision was made. 1 A small amount of serous fluid was suctioned from the middle ear and a Paparella style tube was placed. *' Saline drops were applied. The patient was then awakened and taken to the recovery area in stable condition. Estimated blood loss was less than 5 cc. He tolerated the procedure well without complications. Y General anesthesia is used. i The right ear is examined using the operating microscope. !'The previously placed tube in the external auditory canal is removed. & An incision is made into the tympanic membrane. El The ventilating tube is placed in the incision made in the right ear. 19 The procedure is now performed on the left ear. I An incision is made into the left tympanic membrane. %! A ventilating tube is inserted in the incision that was made in the left ear. What are the CPT* and ICD-10-CM codes reported? CPT® code: 69436-50 1CD-10-CM code: H65.23 Rationale: A tympanostomy is performed using ventilating tubes. The patient had this procedure performed previously. The previously placed tube fell into the external auditory canal. A ventilating tube (Paparella style) is inserted in both the left and right ears using the same surgical technique. Look in the CPT® Index for Tympanostomy/General Anesthesia 69436. General anesthesia is used, which makes 69436 the correct code. The procedure is performed on both the left and right ear, which requires modifier 50. To locate the code for the removal of the ventilating tube in the right ear, turn to Removal/Tube/Ear, Middle in the CPT*® Index. You are referred to 69424. The code description matches the procedure performed but there is a parenthetical note following this code that states, “Do not report 69424 in conjunction with 69205, 69210, 69420, 69421, 69433-69676, 697 10-69745, 69801-69930." Code 69436 is in the range of codes. For this procedure, only code for the tympanostomy with insertion of the ventilating tubes. The removal is included and not reported separately. Next, we need to determine the [CD-10-CM code. The operative note indicated there is serous fluid bilaterally (both ears) and both tympanic membranes are dull, but intact, indicating no rupture of the tympanic membrane. Look in the ICD-10-CM Alphabetic Index for Otitis/media (hemorrhagic) (staphylococcal) (streptococcal)/chronic/with effusion (nonpurulent). You are directed to see Otitis, media, nonsuppurative. Look for Otitis/media/nonsuppurative/chronic/serous H65.2-. 6™ character 3 specifies the condition is bilateral. Glossary Acoustic Neuroma—A tumor of the eighth cranial nerve sheath; although benign, it can press on surrounding tissue and produce symptoms; also called an acoustic or vestibular schwannoma or acoustic neurilemmoma. After-Cataract—When a cataract is removed from the eye, the physician opts to retain the posterior outermost shell so there remains an organic separation between the posterior and anterior chambers. Later, this remaining shell may develop opacities as well, and this is called after-cataract or secondary cataract. Anterior Segment—The cornea up to the vitreous body which includes the aqueous humor, iris, and lens. Aqueous Humor—Fluid that fills the anterior and posterior chamber of the eye. Blepharoplasty—Surgical repair of the eyelid. Cataract—0Opacity of the lens of the eye. Cerumen—The brownish, wax-like secretion formed in the external ear canal to protect the ear and prevent infection. Also known as ear wax. Cholesteatoma—A benign growth of skin in the middle ear, usually caused by chronic otitis media. Choroid—The middle vascular layer between the retina and the sclera in the posterior segment of the eye. The choroid nourishes the retina. Ciliary Body— The muscular portion of the uvea that surrounds the lens and adjusts its shape for near and far vision. Cochlea—The coiled portion of the inner ear that contains the receptors for hearing. 26
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems Conduction—Receptions or conveyance of sound, heat, or electricity. Sound waves are conducted to the inner ear through bones in the skull Conjunctiva—The mucous membrane that lines the eyelids and covers the eyeball’s anterior surface. Cormea—The clear, anterior portion of the sclera. Crystalline Lens—A convex disc suspended on threads just behind the iris. Dacryolith—Calculus in the lacrimal sac or duct. Endolymph—Fluid within the semicircular canals and the tubes of the cochlea of the inner ear. Enucleation—Removal of a structure such as the eyeball. Esotropia—A condition where the eye deviates inward. Eustachian Tube—A tube in the ear linking the middle ear to the nasopharynx. This tube equalizes pressure between the middle ear and the outer world. Evisceration—A procedure where the contents of the eyeball are scooped out but the sclera shell remains connected to the eye muscles so that a prosthesis fitted into the globe will have natural movement. Exenteration—Removal of a complete structure and the surrounding skin, fat, muscle, and bone. External Auditory Meatus—Tube that extends from the pinna of the ear to the tympanic membrane. Exotropia—A condition where the eye deviates outward. Glaucoma—An eye disease caused by increased intraocular pressure that damages the optic disk and causes vision loss. Usually results from faulty fluid drainage from the anterior eye. Goniotomy—A procedure where an opening is made in the trabecular meshwork of the front part of the eye. The provider uses a goniolens during the procedure. Hypertropia—A condition of misalignment of the eyes (strabismus), whereby the visual axis of one eye is higher than the fellow fixating eye. Incus—The middle ossicle (bone) in the middle ear. Iris—The muscular colored ring between the lens and the cornea; regulates the amount of light that enters the eye by altering the size of the pupil at its center. Limbus—The border where the cornea meets the sclera. Also known as the sclerocorneal junction. Malleus—The ossicle (bone) in the middle ear that picks up vibration from the tympanic membrane, which is in contact with the tympanic membrane and the incus. Mastoid—A bone in the skull just behind the ear containing tiny air cells that also form a conductive path for sound. Mastoiditis—Inflammation of the air cells of the mastoid process. Méniére’s Disease—A disease associated with increased fluid pressure in the inner ear and characterized by hearing loss, vertigo, and tinnitus. Microtia—A congenital deformity of the ear whereby the pinna (external ear) is underdeveloped. Nystagmus—Reflexive jerky eye movements as a response to the messages of the inner ear. Optic Nerve—The nerve that transmits images from the eye to the brain. Damage to the optic nerve can result in loss of or impaired vision. Ossicles—The small bones of the middle ear; the malleus, incus, and stapes. Otitis Media—Inflammation of the middle ear with accumulation of serous (watery) or mucoid fluid. Otitis Media—Inflammation of the middle ear with accumulation of serous (watery) or mucoid fluid. Oval Window—A membrane covered window from the inner ear to the middle ear. Perilymph—Surrounds the semicircular canals, utricle, and saccule of the vestibular system, and it surrounds the ducts in the cochlea. Inner channels are filled with endolymph. Puncta—Tiny openings of the tear ducts. Pupil—The opening at the center of the iris. Refraction—The bending of light rays as they pass through the eye to focus on a specific point on the retina; also, the determination and correction of ocular refractive errors. Retina—The innermost, light-sensitive layer of the eye; contains the rods and cones, the specialized receptor cells for vision. Retinal Detachment—The retina is freed from the blood-rich choroid at the back of the eye. When the retinal layer floats away, it loses its supply of nutrients. Nutrients must return, or vision is lost. Retrobulbar—Space behind the eye. Round Window—A membrane-covered window that separates the middle ear from the inner ear, allowing vibrations to pass through to the cochlea. Sclera—The outer coat of the globe and is continuous with the dura via the dural sheath of the optic nerve at the back of the eye. The sclera at the front of the eye is known as the white of the eye and is covered with a thin protective layer of conjunctiva. Sclerocorneal Junction—The ring where the cornea meets the sclera. Also known as the limbus. Secondary Cataract—See After-Cataract. Semicircular Canals—The three curved channels of the inner ear that hold receptors for equilibrium. Stapes—The ossicle (bone) in the middle ear that is in contact with the inner ear. Strabismus—A condition where the eyes are not properly aligned with each other. 27
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Chapter 15: Eye and Ocular Adnexa, Auditory Systems Tenon’s Capsule—Connective tissue surrounding the posterior eyeball. Trachoma—An infection caused by Chlamydia trachomatis leading to inflammation and scarring of the cornea and conjunctiva; a common cause of blindness in underdeveloped countries. Tympanic Membrane—The membrane between the external auditory canal and the middle ear (tympanic cavity); the eardrum. It serves to transmit sound waves to the ossicles of the middle ear. Uvea—The middle, vascular layer of the eye; consists of the choroid, ciliary body, and iris. Vestibular Schwannoma—A benign tumor arising from nerve cells of the auditory nerve (eighth cranial nerve). Vestibule—The chamber in the inner ear that holds some of the receptors for equilibrium. Vertigo—A whirling or spinning perception of motion resulting in the loss of balance. Visual Field—The total area that can be seen by peripheral vision. Vitreous Humor—A gel-like mass that fills the large posterior segment of the eye. 28
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