Roger Forchetta, a 33-year-old male, came in to our ophthalmology office today. I last saw him 6 years ago when he had a corneal ulcer on his right eye. This is now cleared. He states that over the last few weeks, his vision is “a bit off.” I began with a complete, interval history. He denied any specific trauma or problems with his eyes prior to this latest concern. Overall, this patient is a healthy male with an admitted diet filled with a great deal of fast food and restaurant food. His external ocular and adnexal areas were unremarkable, free from injury or infection. The patient has a normal corneal anterior chamber and iris but with very slow dilating pupils. Ophthalmoscopy shows there is no pseudoexfoliation, but there are dense juvenile nuclear cataracts on both eyes, the right greater than the left. I counseled him regarding cataract surgery of this right eye first, and then the left eye; the need for postop correction; a 4- to 6-week recovery time; and the type of procedure. He agreed to schedule the procedure for next Friday. Kathy, my assistant, obtained the appropriate consent form signatures.. Determine the most accurate procedure codes, using the CPT and HCPCS code sets and modifier(s), if appropriate.
Roger Forchetta, a 33-year-old male, came in to our ophthalmology office today. I last saw him 6 years ago when he had a corneal ulcer on his right eye. This is now cleared. He states that over the last few weeks, his vision is “a bit off.”
I began with a complete, interval history. He denied any specific trauma or problems with his eyes prior to this latest concern. Overall, this patient is a healthy male with an admitted diet filled with a great deal of fast food and restaurant food.
His external ocular and adnexal areas were unremarkable, free from injury or infection. The patient has a normal corneal anterior chamber and iris but with very slow dilating pupils. Ophthalmoscopy shows there is no pseudoexfoliation, but there are dense juvenile nuclear cataracts on both eyes, the right greater than the left.
I counseled him regarding cataract surgery of this right eye first, and then the left eye; the need for postop correction; a 4- to 6-week recovery time; and the type of procedure. He agreed to schedule the procedure for next Friday. Kathy, my assistant, obtained the appropriate consent form signatures..
Determine the most accurate procedure codes, using the CPT and HCPCS code sets and modifier(s), if appropriate.
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