The appropriate diagnosis code for the staged vitrectomy (or aspiration) to remove the silicone oil is the original diagnosis from the primary procedure.Ĭonflict and misunderstandings arise when chart notes (during the postoperative period of the primary procedure) state “retina stable” or “retina flat,” as if a satisfactory endpoint has been reached. From the patient’s perspective, the presence of silicone oil causes poor vision and is undesirable. However, the eye doesn’t reach stability until completion of the final staged procedure-silicone oil removal. Surgeons often plan to remove the oil as the eye approaches stability. The following four examples will shed some light on the best ICD-10 code and the need for any modifiers.
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