AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2014 Issue 4; Ask the Editor

Pars Plans Vitrectomy without Mention of Instillation of Oil, Air or Fluid

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?  ...

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