Question: Yesterday I performed an uncomplicated cataract extraction via phacofragmentation with IOL insertion, which was billed as CPT code 66984. Today I discovered a retained lenticular fragment in the anterior chamber. What is the correct CPT and ICD-9 code for this return to operating room?

Answer: Depending on your operative report, it may be:

• 66840 Removal of lens material; aspiration technique, one or more stages
• 66850 phacofragmentation, with aspiration
• 66852 pars plana approach, with or without vitrectomy
• Modifier -78 Unplanned return to operating or procedure room for a related procedure by the same physician during the postoperative period, should be appended to the surgical code.

Payment will be 80 percent of the allowable. Do not begin a new global period.

The appropriate diagnosis is 998.82 Cataract fragments in eye following cataract surgery.