Fwd: Cirurgia de vitrectomia

- O procedimento vitrectomia inclui a pelagem de membrana, tamponamento e fotocoagulação com laser? Codificam-se separadamente?
- A cerclage codifica-se (é a minha opinião) para além da vitrectomia?


(Responde Fernando Lopes=

 
 
Estas questões não são fáceis de responder na atual ICD-10-PCS por inextistência de instruções de 'code also' ou de 'integral to'.
Fazendo uma pesquisa exaustiva no Coding Clinic, encontramos:
 
CC 1Q 1994 page 16: Removal of lens fragments from vitreous following cataract extraction
- The removal of lens fragments from vitreous following cataract extraction done by vitrectomy with scleral buckling is coded as scleral buckling;
 
CC 1Q 1994 page 17: Repair retinal detachment and subluxed lens
- Question:
In order to repair the subluxed lens and the retinal detachment, the surgeon performed a posterior segment vitrectomy, posterior phacofragmentation and aspiration, scleral buckling, fluid gas exchange and limited indirect laser. What codes are necessary to describe this procedure?
- Answer:
Assign code 14.49, Repair of retinal detachment with scleral buckling and implant, Other scleral buckling, as the principal procedure. Additionally, assign code 14.34, Repair of retinal tear by laser photocoagulation, to completely describe the repair, and code 14.75, Injection of vitreous substitute, for the fluid gas exchange.
 
CC 3Q 1996 page 4: Phacoemulsification of cataract w/vitrectomy & lens placement
- Faco + LIO + vitrectomia codificam-se separadamente
 
CC 3Q 1996 page 5: Fluid or gas exchange with or without vitrectomy
- A fluid/gas exchange is not integral to a vitrectomy and can be performed as a stand alone procedure;
 
CC 3Q 1996 page 5: Vitrectomy with membrane peeling
- A membrane peeling is not inherent in a vitrectomy
 
CC 1Q 1998 page 6: Insertion of intravitreal Ganciclovir implant in eye
- Ganciclovir is not a vitreous substitute.
 
CC 1Q 1999 page 11: Vitrectomy with silicone oil removal for vitreous opacity
- Pars plana vitrectomy with removal of silicone oil for vitreous opacities (silicone oil fill)
- codificada 'Outras operações no vítreo'
 
CC 2Q 2010 pages 4-5: Retroprosthetic Membrane Status Post Placement of Artificial Cornea Device
- Retroprosthetic membrane status post artificial corneal device: revision vitrectomy with retroprosthetic membrane removal via pars plana and intravitreal injection of Avastin.
- Codificada a vitrectomia e a injeção de Avastin.
 
CC 4Q 2011 pages 105-106: Vitreomacular Adhesion
- Question:
A 76-year-old man presented with blurred vision in his left eye, which he had been suffering from for six months. Examination revealed a blunted foveal reflex. Using optical coherence tomography, the presence of vitreomacular traction was clearly identified. The posterior vitreous face, the focal adhesions of the vitreous to the parafoveal area, and traction on the retina were noted. The scans also showed a partial-thickness macular hole that was developing secondary to the traction. The patient underwent surgical treatment involving removal of the posterior vitreous. What are the appropriate diagnosis and procedure codes?
- Answer:
Assign code 379.27, Vitreomacular adhesion, as the principal diagnosis. Code 362.54, Macula cyst, hole, or pseudohole, should be assigned as a secondary diagnosis. Assign code 14.74, Other mechanical vitrectomy, for the procedure.
 
CC 4Q 2013 pag 83-85: Epiretinal Visual Prosthesis:
- The Implantation of epiretinal visual prosthesis Includes lens removal if present, scleral buckling, vitrectomy, epiretinal membrane peeling and pericardial grafting
- The Removal of epiretinal visual prosthesis Includes 360 degree limbal peritomy and vitrectomy if performed, and device extraction;
 
CC 4Q 2014 pages 35-36: Vitrectomy with Air/Fluid Exchange
- Question:
A patient with retinal detachment of the left eye underwent surgical repair. Provider documentation states that a core vitrectomy was done, followed by 360 degrees peripheral vitreous base dissection, and thorough vitrectomy for 360 degrees. Once the retinal tear was identified, partial air-fluid exchange was performed, photocoagulation/endolaser was placed surrounding the retinal tear, and air was replaced with 20% sulfur hexafluoride gas. What is/are the appropriate root operation(s) for the vitrectomy and air replacement with 20% sulfur hexafluoride gas?
- Answer:
In this case, the root operation is "Excision," because the entire vitreous is not removed during a vitrectomy. Do not code the instillation of oil, air or fluid into the vitreous following vitrectomy, because it is integral to the procedure. The substance instilled functions like packing inside the eye: it holds the retina and other structures in the proper position. The oil, air or fluid does not replace or supplement the vitreous. The body secretes fluid that over time fills the void left by the vitrectomy. Assign the following ICD-10-PCS code for the vitrectomy: 08B53ZZ Excision of left vitreous, percutaneous approach 
 
CC 4Q 2914 pages 36-37: Pars Plana Vitrectomy without Mention of Instillation of Oil, Air or Fluid
- Question:
A patient presents for treatment of diabetic vitreous hemorrhage, tractional retinal detachment, and proliferative diabetic retinopathy of the right eye. The provider documented that a posterior pars plana vitrectomy was done, followed by opening of a subhyaloid hemorrhage covering the entire posterior pole, removal of  traction from the paramacular region, and removal of hemorrhage from the posterior pole. However, the instillation of oil or gas was not documented. What is the appropriate root operation for the vitrectomy, when there is no documentation that the vitreous was replaced with oil or gas? 
- Answer:
Although instillation of oil, air, or fluid was not specifically documented, it is necessary to replace the vitreous with one of these substances. However, do not code the instillation separately as it is inherent to the performance of a vitrectomy. Assign the following ICD-10-PCS code for the vitrectomy: 08B43ZZ Excision of right vitreous, percutaneous approach 
 
CC 2Q 2015 page 24: Intravitreal and Subconjunctival Injections
- Substances injected during an operative procedure are typically not coded separately. Therefore, ICD-10-PCS codes are not assigned in most cases for the injection of substances administered as part of a more definitive surgery, since they are integral to the procedure.
 
Algumas conclusões, valorizando as edições mais recentes (2014 e 2015, já em ICD-10-PCS):
 
- o que diz o Coding Clinic não é imutável: pode vir a ser corrigido ou desdito posteriormente;
- a indentação (scleral buckling) inclui a vitrectomia (se também realizada);
- a vitrectomia é habitualmente, uma excisão, não uma ressecção;
- a vitrectomia inclui o tratamento da tração da retina e do buraco macular;
- a vitrectomia inclui a troca fluido/gás (se também realizada) assim como a remoção de óleo de silicone;
- a fotocoagulação laser codifica-se separadamente;
- a faco/LIO e a pelagem de membranas são independentes da vitrectomia;
- as substâncias injetadas durante uma cirurgia (antibióticos, por exemplo), bem como as instiladas (óleo (de silicone), gás ou fluido) durante uma vitrectomia, fazem ("typically") parte dela e não se codificam ("in most cases") separadamente. O Avastim parece ser uma exceção.
- apesar de "necessary to replace the vitreous with one of these substances" durante a cirurgia de vitrectomia porque funciona como "packing inside the eye: it holds the retina and other structures in the proper position" essa substância "does not replace or supplement the vitreous".
 
Resta dizer que:
- as cirurgias não são sempre iguais;
- os relatos operatórios (e, quando necessário, a explicação do cirurgião para indicar o objetivo dos procedimentos) são fundamentais para a seleção da Root Operation.
- o Coding Clinic afirma que até as entradas do índice alfabético não são categóricas e devem ser equacionadas perante uma cirurgia concreta. Veja-se o que acontece com a codificação das desmontagens das ostomias digestivas.
 
Coders should note that although the Index entry under "Takedown, Stoma" leads to "Repair," there are various types of procedures with different root operations for stoma takedown. Coders should not assign ICD-10-PCS procedure codes based on where the Index directs without further review of the documentation to determine what was actually done. (Coding Clinic, 3Q 2016, pages 3-7: Stoma Creation and Takedown Procedures).
 
- de tal maneira assim é que, na versão de 2018, o índice deixa de apresentar Takedown / Stoma see Repair, e passa a ter: Takedown / Stoma see Excision | see Reposition.
- um outro exemplo é a fotocoagulação laser: só vamos codificá-la como 'destruição' quando se referir a lesões coriorretinianas. Para reaplicar a retina ou tratar rasgaduras o enquadramento é em 'reparação'.
 
 
Fernando Lopes