JAN 19, 2023
Canceled Cataract Surgery for Chalazion Removal
Question: A patient was scheduled for cataract surgery but presented to the ambulatory surgery center (ASC) on the scheduled day of surgery with a large infected chalazion. The surgeon canceled the cataract surgery and removed the chalazion instead. How do we properly code this procedure?
Code the chalazion removal surgery with the appropriate diagnosis code. Preoperative documentation should include examination notes by the physician outlining the change in plan and an updated consent form. Since performed in the ASC, the place of service would be 24.
From Coding Coach: The Complete Ophthalmic Coding Reference
||Excision of chalazion; single
||Excision of chalazion; multiple, same lid
||Excision of chalazion; multiple, different lids
||Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple