Operative Note: Chalazion incision and drainage of the right eye Procedure: The right eye was prepped and draped for the procedure. Chalazion forceps were used to grasp the upper eyelid. The surface of the chalazion was incised. The contents of the chalazion were curetted. Chalazion forceps were removed. Hemostasis was achieved. Maxitrol ointment was placed in the eye with an overlying eye pad.

Question

The patient was transferred to the recovery area in stable condition.

Abstract from Documentation:

1. Refer to Chalazion in the Alphabetic Index. What documentation is needed to assign a correct CPT code?

2. Time to Code:

Answer 1

1. Documentation of which eyelid and whether multiple or single. Note that the operative note refers to incision and drainage, and the subcategory is under the title of Excision and Destruction. The documentation states that the physician “cut into the chalazion” and subsequently “curetted” the cyst. The technique described is similar to excision.

2. Index:
Chalazion, Excision, Single
Code(s):
67800-E3 Excision of chalazion; single