Diagnoses: Atrophic macular degeneration with subfoveal occult choroidal neovascularization, left eye. Atrophic macular degeneration, right eye.
A 72-year-old female, who was referred by her optometrist to an ophthalmologist, arrived for her 11 a.m. appointment on April 1. The ophthalmologist is a specialist in retinal-vitreous surgery, and he discussed with the patient treatment options for visual changes in her left eye. The patient had noticed gradually worsening Amsler grid changes and central vision distortion since January. Visual acuity, blood pressure, slit lamp exam, tension, biomicroscopy, optical coherence tomography and fluorescein angiogram studies were performed. The studies revealed loss of visual acuity of the left eye; blood pressure was within normal limits; persistent central pigment epithelial detachment, trace fluid and hemorrhage along the nasal foveal margin; and prominent perifoveal indistinct drusen of the left eye.
Upon completion of the Level 2 E/M service, the physician informed the patient of the diagnosis of atrophic macular degeneration with subfoveal occult choroidal neovascularization, left eye, and atrophic macular degeneration of the right eye. He discussed the newly FDA-approved intravitreal injection of Lucentis for this condition. The patient was treated with the intravitreal injection of Lucentis, 0.1 mg, and follow-up evaluation scheduled in 2 weeks.
Instructions: Assign ICD and CPT/HCPCS codes for this case.
