UKOA Cataract Coding Handbook

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Amelia Mercy Collins
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UKOA Cataract Coding Handbook Cataract Cataract is a clouding of the natural clear focussing lens inside the eye, usually associated with age (senile).

1 UKOA Cataract Coding Handbook Cataract Cataract is a clouding of the natural clear focussing lens inside the eye, usually associated with age (senile). Other causes include diabetic, other metabolic diseases, drugs, congenital lens birth defects, genetic (familial, inherited), trauma, other eye disease, syndromes. It causes blurred vision, glare, sometimes double vision, difficulties driving at night. It is usually operated on only when the patient decides their symptoms warrant the risks of the surgery. >90% are done under local anaesthetic. The standard operation is the phacoemulsification in which the lens is removed with instruments including an ultrasound probe which emulsifies (liquidises) the lens. The lens is reached via an incision in the wall of the eye, and a small opening (capsulotomy, capsulorrhexis) in the anterior lens capsule (capsular bag) which is a thin transpraent film which surrounds the lens. Every effort is made not to rupture the posterior capsule (posterior capsular rupture, PCR, commmonest complication) nor for the vitreous jelly behind it to come forward (vitrous prolapse, vitreous loss) as these interfere with inserting the artificial intraocular lens implant (IOL) which is usually inserted after removal of the cataract and which replaces the focusing power of the lens material the surgeon has removed.

Diagnositic codes for cataract Code Description Code Senile incipient cataract H25.0 Senile nuclear cataract H25.1 Senile cataract, morgagnian type H25.2 Other senile cataract H25.

2 Diagnositic codes for cataract Code Description Code Senile incipient cataract H25.0 Senile nuclear cataract H25.1 Senile cataract, morgagnian type H25.2 Other senile cataract H25.8 Senile cataract, unspecified H25.9 Infantile, juvenile and presenile cataract H26.0 Traumatic cataract H26.1 Complicated cataract H26.2 Drug-induced cataract H26.3 After-cataract H26.4 Other specified cataract H26.8 Cataract, unspecified H26.9 Diabetic cataract H28.0 Cataract in other endocrine, nutritional and metabolic diseases H28.1 Cataract in other diseases classified elsewhere H28.2 Congenital cataract Q12.0 Advice - Mature cataract/advanced cataract/white cataract = H26.9 Cataract, unspecified

3 Brown cataract is an advanced nuclear catract= Senile nuclear cataract H25.1 Nuclear cataract: If there is no mention of senility; then this should be coded as Other specified cataract.. H26.8. Age cannot be used as a modifier. Mixed nuclear sclerotic and posterior polar cataract: where it is documented that a cataract is of a mixed type then all types should be coded separately = H25.1 Senile nuclear cataract & H26.8 Other specified cataract. 1 unit has said in their local guidance Non complicated surgery in Cataract Service in patients over 50 will be classified as Senile.??H25 I don t think this is allowed Advice on coding for diabetic cataracts please? all cataracts in diabetics? Must say diabetic cataract? Co-morbidities I have not attempted this, should we include? It could be a big piece of work and also if do, maybe as appendix? Also I note Derek said its likely to change and simplify soon. Codes for cataract surgery The vast majority of cataract surgery = C75.1 Insertion of prosthetic replacement for lens & C71.2 Phacoemulsification of lens. Other types of cataract surgery, often using techniques which were previously the norm before phaco, or cataract related surgery are sometimes used. Code Description Code Insertion of a prosethci replacement for lens C75.1 Phacoemulsification of lens C71.2 Extracapsular cataract extraction C71.9 Intracapsular cataract extraction C72.9 Mechanical lensectomy C74.3 Insertion of prosthetic replacement for lens using suture fixation C75.4 Any others? Revision of prosthetic replacement for lens C752 Complex Surgery It is not uncommon to undertake other procedures at the same time as cataract surgery. This may be: in a planned way because the eye/operation is obviously r very likely going to require more intervention;

4 in a planned way as an adjunct because of another condition (e.g. intravitreal injection for co=-existing retinal disease); because the operation becomes technically more complex than expected during the procedure; because of a complication. Just because an operation is complex or there is another procedure does NOT necessarily mean there has been an unplanned /unexpected complication. Advice on procedures often undertaken primarily to support the cataract surgery Vitrectomy may be anterior or posterior. Posterior vitrecomy (pars plan vitrecomty/ppv, 3 port vitrecomty) is a specialist vitreouretinal procedure in which 3 openings are made in the sclera and specialst VR instruments use to clear most of the vitreous jelly. Anterior vitrectomy can be undertaken by cataract surgeon in which a small amount of the front part of the vitresou jelly is removed entering through the front of the eye.. :Most anterior vitrectomies are due to a complication but not all. Anterior vitrectomy = Vitrectomy using anterior approach C79.1 When both posterior vitrectomy and cataract procedures are performed within the same operation; the most resource intensive procedure would be the vitrectomy and should be sequenced in a primary position Vitrectomy using pars plana approach C79.2 Kenalog Intravitreal Injection or Triamcinolone intravitreal injection =. Kenalog is a brand name for a steroid called triamcinolone which is often used during anterior vitrectomy following complications or in complex surgery, to make the normally transparent vitreous visible to ensure all vitreous protrugin forward is removed Different units are doing it differently is it = C79.4 Injection into vitreous body NEC& X38.1 Injection of triamcinolone for local action or is it C693 injection into AC. Pupil and iris problems. There may be extra procedure requirements because of a small pupil, floppy iris syndrome, or adhesions of the iris (synechiae) to tissue in front of the iris (anterior syencehiae) or tissue behind the iris (posterior synechiae).the following procedures may be used alone or in combination. Pupil stretch/iris stretch. The pupil may be surgically stretched to widen it = C64.6 Stretching of iris Intracameral phenylephrine: An injection into the anterior chamber of the eye (intracameral injection, IC injection) of a phenylephrine or a phenylephrine containing compound may be undertaken to widen the pupil medically or to prevent it getting smaller in higher risk or complex cases = C693 injection into AC for phenylephrine

5 Iris hooks. Multiple small Iris Hooks can be used to hold the pupi open or tighten floppy iris tissue = C64.7 Insertion of iris hooks Malyugin ring: A flexible Malyugin Ring can be inserted to hold the pupil open = C64.6. stretching of iris Y02.2 Insertion of prosthesis into organ NOC Synechiolysis: The adhesions (synechiae) may be separated or opened that is Synechiolysis = C64.8 Other specified other operations on iris, Y18.1 Freeing of adhesions of organ NOC Iridotomy/peripheral iridotomy: A section of iris may be removed, Iridotomy, to widen the pupil, reduce iris prolapse, to control eye pressure or other reasons = C592 ssurgical iridotomy Other Capsular tension ring: A rigid Morcher ring or capsular tension ring can be inserted to stabilise the capsular bag when the zonules are weak = C77.6 Insertion of capsule tension ring Suture IOL, If an IOL is sutured, this should be coded not as separate sutures and IOL but = Insertion of prosthetic replacement for lens using suture fixation C754 Intracameral Vision blue. Drug Vision blue may be injected into the anterior chamber (IC injection) in complex cases for better visulaisation to make the capsule more clear to capsulotomy e.g. with a dense or white cataract or a corneal scar obscuring the view = = C69.3 injection into AC. Intracameral Miochol. The drug Miochol may be injected into the anterior chamber (IC injection) in complex cases, to reduce the size of the pupil or tighten the risi towards the end of the operation e.g. to insert an anterior chamber IOL or help with iris prolapse = C69.3 injection into AC. Procedures sometimes undertaken for other disorders It is not uncommon where there are retinal problems co-existing to combine an intravitreal injection of some sort with the phaco at the beginning or end of the procedure. Some high cost drugs are specifically coded: Injection into vitreous body NEC C794 Injection of steroid into posterior segment of eye C892 Avastin intravitreal injection = C79.4 Injection into vitreous body NEC, X93.1 Subfoveal choroidal neovascularisation drugs Band 1 Aflibercept (Eyelea) intravitreal injection = Intravitreal Injection C79.4 Injection into vitreous body NEC, X93.1 Subfoveal choroidal neovascularisation drugs Band 1

6 Ranibizumab (Lucentis) Intravitreal Injection =. C79.4 Injection into vitreous body NEC, X93.1 Subfoveal choroidal neovascularisation drugs Band 1 Ozurdex Intravitreal Dexamethasone injection. Different units are doing it differently is it Injection of a long acting drug implant into the vitreous = C79.4 Injection into vitreous body NEC, X93.2 Macular oedema drugs Band 1 OR is it Insertion of sustained release device into posterior segment C89.1 & X93.2 Macular oedema drugs Band 1 Fluocinolone acetonide intravitral implant (Iluvien) Is it Injection of a long acting drug implant into the vitreous = C79.4 Injection into vitreous body NEC, X93.2 Macular oedema drugs Band 1 OR is it Insertion of sustained release device into posterior segment C89.1 & X93.2 Macular oedema drugs Band 1 Complications When using bespoke EPRs such as OpenEyes and Medisoft, it is important where possibly to use the specific field to record complications using standard and consistent terminology. Where staff identify what sounds like a complication in the operation note details, but there is a none recorded in the complication field, they should seek senior clinical advice. It may not be a complication, or it may be, in which case it might need to be transferred to the correct field with the surgical note taker receiving feedback. Complications during surgery Posterior capsular rupture = Posterior capsular tear = posterior capsular break = PCR) - no vitreous loss (or no vitreous loss or anterior vitrecomy recorded) Different units are doing differently is it Record as T81.2 Accidental puncture and laceration Accidental puncture and laceration during a procedure, not elsewhere classified. Vitreous loss = vitreous prolapse = unplanned vitrecomy = PCR with vitreous loss Different units are doing differently is it Record as T81.2 Accidental puncture and laceration Accidental puncture and laceration during a procedure, not elsewhere classified. Dropped Nucleus = retained lens fragments this is when there is a PCR or a zonule rupture and part of all of the cataract drops backwards into the vitreous jelly. It is a serious complication and often requires another operation. It usually implies vitreous loss but not always true clinicians?

7 Different units are doing differently is it Record as T81.2 Accidental puncture and laceration Accidental puncture and laceration during a procedure, not elsewhere classified OR is it H27.1 dislocation of lens Zonular dialysis/zonular rupture. This is when the supporting fibres at the periphery of the capsular bag given way. It may or may not be associated with vitreous loss and need for vitectomy. = T81.8 Other complications of procedures, not elsewhere classified Some but not all clinciians say If there is no mention of a leak/rupture/loss of vitreous then this is not a complication. is this agreed with or not? Note the NOD audit records and reports it as a complication Iris Trauma/iris tear/iris damage Different units are doing differently is it Record as T81.2 Accidental puncture and laceration Accidental puncture and laceration during a procedure, not elsewhere classified Is is a complication? Anterior Capsular Tear, Different units are doing differently is it Record as T81.2 Accidental puncture and laceration Accidental puncture and laceration during a procedure, not elsewhere classified Is it a complication? NOD auditrecords and reports it? Iris Prolapse, Different units are doing differently is it Record as T81.2 Accidental puncture and laceration Accidental puncture and laceration during a procedure, not elsewhere classified Is it a complication? Iris prolapse is thought by many not to be a surgical complication; it just makes the surgery more complex. (patients may be documented as having floppy iris). I would agree with that; its not a medisfot complication but I think a difficulty but is reported by NOD as one Hyphaema

8 T81.8 Other complications of procedures, not elsewhere classified; Y60.0 Unintentional cut, puncture, perforation or haemorrhage during surgical and medical care: During surgical operation Other some units use an anterior vitrecomy or using a different IOL (e.g. different brand, or AC IOL) as a proxy to identify and code for PCR or vitreous loss this may be totally accurate though what do we think? Descemets Membrane Detachment dep on whether due to surgeon. Not due to surgeon = H18.3 Changes in corneal membranes; Due to Surgeon = T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified What about descemets memberane tear/damage/endothelial damage? What about phaco wound/burn problems this is listed as a NOD complication What about choroidal or suprachrooidal haemorrhage a really serious complication? Complications post Cataract surgery Dropped Nucleus; Retained lens matter (natural); Retained lens matter (prosthetic) H59.8 Other postprocedural disorders of eye and adnexa; Y83.6 Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure Prosthetic retained lens: T85.2 Mechanical complication of intraocular lens Retained Viscoelastic: do NOT code as a complication. Usually even if any is left behind in the eye, the body will absorb this. Corneal abrasion: This is not considered to be a complication by some units but Note the NOD audit records and reports it as a complication What about corneal odema?. What about postop uveitis, endophthalmitis, postop cystoid macular oedema More than one complication if the complications have a clear code e.g. T81.2 or T81.5 then use both codes rather than a T81.8 to cover both. Not sure I understood this bit Y codes Usually if a complication occurs during eye surgery then an Y60.0 Unintentional cut, puncture, perforation or haemorrhage during surgical operation would be added after the T code. For a readmission to correct a complication for cataract surgery an Y83.1 Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later misadventure at the time of the procedure would follow the T code.

9 Useful abbreviations and terms used by clinicians in cataract including some ocular co-morbidities This probably needs some additions Abbreviations Description Code ICD10 OPCS 4.8 AC Anterior Chamber = fluid cavity between cornea and lens AC IOL IOL in unusual place in front of iris imlies complex surgery or a complication AMD = ARMD Age-Related Macular Degeneration, age H35.3 related degeneration of the central part of the retina used for detailed vision Aphakia Absence of a lens H27.0 AS Anterior segment = front half of the eyeball Asteroid Benign vitreous jelly degeneration causing H43.2 hyalosis visible flecks in vitreous Astigmasitm Type or glasses prescription (refractive error0 H52.2 caused by oval shape of cornea or lens BDR Background Diabetic Retinopathy E1.-D, H36.0 A BRAO Branch Retinal Artery Occlusion H34.2 Blepharitis Chronic low grade irritation of the eyelid H01.0 edges, could raise the risk of endophtahlmitis if severe BRVO Branch Retinal Vein Occlusion H34.8 CF Counting fingers vision CMO Cystoid Macular Oedema, fluid in central H35.8 retina, potential postop complication CNV = CNVM Choroidal Neovascular Membrane (wet AMD) H31.8 Cortical cataract Cataract in spoke like shape in periphery of the lens H26.8 Other specified cataract CRVO Central Retinal Vein Occlusion H34.8 CSMO Clincally Significant Macular Edema H35.8 DR ECCE ERM Diabetic retinopathy Extracapsular Cataract Extraction, previously most common techynique before phaco, occasionally still used Epiretinal Membrane aksk macular pucker aka cellophane macuoopathy, degeneration of the central retina on its surface H35.3 C71.9 Fragmatome Lensectomy This is a mechanical cataract removal technique using ultrasound to destro the lens prior to aspiration. I thought mechanical not ultrasound FTMH Full Thickness Macular Hole, degeneration of H35.3 C74.3 Mechanical lensectomy; Y11.5 Ultrasonic destruction of organ NOC

10 Fuchs corneal dystrophy Hypermature Cataract ICCE IC injection IFIS = floppy iris the central retina with total loss small area of tissue Inhterited disorder of the inner layer of cornea, worse with age, can cause corneal oedema/clouding especially after cataract surgery So adcanved a cataract that some liquefies, makes cataract surgery very risky. IntraCapsular Cataract Extraction, technique even older than ECCE. Removal of who lens and capsular bag. Intracameral injection, injection drug into the AC Intraoperative floppy iris syndrome lax iris can cause intraop problems including iris prolapse and small pupil, increased the risk of serious complications. rare unless taking certain systemic drugs H18.5 H25.2 Senile cataract, morgagnian type H21.8 IOL IntraOcular Lens (Prosthetic) implant Z96.1 IOP IntraOcular Pressure Lamellar hole degeneration of the central retina with partial H35.3 loss small area of tissue LO lens opacity ie cataract MGD blepharitis MH Macular hole, degeneration of central part of retina. Can be lamellar or full thickness. NPDR NonProliferative Diabetic Retinopathy E1-.-D, H36.0 NPL NS (+,++,+++; 1-5) No Perception of Light Nuclear sclerosis, commonest age related (senile) cataract change, clouding in central part (nucleus) of lens ++ and 1-5 is grading of degree from little to total opacity of the lens centre A H25.1 NTG Normal Tension Glaucoma open angle glaucoma where IOP is in normal range. Codes as POAG H40.1 NVG NeoVascular Glaucoma, severe form of H40.5 glaucoma which complicates eye disease OCT Optical Coherence Tomography OD Right Eye OHT Ocular Hypertension raised IOP without glaucoma damage to nerve and vision OS Left Eye PACG Primary Angle Closure Glaucoma H40.2 PAS Peripheral Anterior Synechiae adhesions iris H21.5 to the front at its edge PCIOL Posterior Chamber IntraOcular Lens. Usualy Z96.1 form of IOL in the capsular bag PCLO Posterior Capsular Lens Opacification H26.8 C72.9 H40.0

11 PCO Posterior Capsular Opacification aksk after H26.4 cataract treated by laser PDR Proliferative Diabetic Retinopathy E1.-D, H36.0A PDS Pigment Dispersion Syndrome H21.2 Phacoor PE phacoemulsification, often taken to mean phaco and IOL even though IOL not written PI Peripheral Iridotomy C62.2 POAG Primary Open Angle Glaucoma H40.1 PPV Pars Plana Vitrectomy C79.2 PS Posterior Synechiae H21.5 PSC = PSCO Posterior Subcapsular Cataract or Posterior H26.8 Subcapsualr Opacity clouding primarily at back of the lens, more commonly seen in diabetics, younger patients and those caused by steroids, but can be senile. More likely to be rapidly progressive PVD Posterior Vitreous Detachment, usuall bening H43.8 shrinkage of vitreous jelly causing flaoters and flashes, can lead to retinal detachment PXF Pseudoexfoliation Syndrome flakes of H40.1 material depoted inside eye riase the risks of glaucoma and serious phaco complications RP Retinitis Pigmentosa, inherited degeneration H35.5 of the retina SLM Synthetic Lens Material Synechiae Adhesions of the iris to other tissue in eye H21.5 Sulcus IOL IOL placed behind the iris but in front of the capsular bag. Usually usaed if a complication Vity Vitrecomy

UKOA Cataract Coding Handbook

UKOA Cataract Coding Handbook This handbook is to support teams of clinicians, coders and managers involved in cataract care to better understand each other s area of expertise and to facilitate working