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Removal of Eye
65091 Evisceration of ocular contents; without implant
65093 Evisceration of ocular contents; with implant
65101 : Enucleation of eye; without implant
65110 : Exenteration of orbit (does not include skin graft), removal of orbital contents; only
65175 : Removal of ocular implant
Excision (Cornea)
65420 Excision or transposition of pterygium; without graft
65426 Excision or transposition of pterygium; graft
Keratoplasty
65710 Keratoplasty (corneal transplant); anterior lamellar
65730 Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
65750 Keratoplasty (corneal transplant); penetrating (in aphakia)
65755 Keratoplasty (corneal transplant); penetrating (in pseudophakia)
65756 Keratoplasty (corneal transplant); endothelial
Anterior Chamber
65820 Goniotomy
Trabeculotomy
65850 Trabeculotomy ab externo
65855 Trabeculoplasty by laser surgery
66174 Transluminal dilation of aqueous outflow canal; without retention of device or stent
Aqueous Shunt
66179 Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft
66180 Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft
66183 Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach
66184 Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft
66185 Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft
Intraocular Lens Procedures
66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation.
66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)
66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation
66985 Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal
67025 Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure)
67028 Intravitreal injection of a pharmacologic agent (separate procedure)
Vitrectomy
67036 Vitrectomy, mechanical, pars plana approach;
67039 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation
67040 Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation
67041 Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker)
67042 Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil)
67043 Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation
Retina Detachment
67101 Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy
67105 Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
67107 Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid
67108 Repair of retinal detachment;with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique
67110 Repair of retinal detachment;by injection of air or other gas (eg, pneumatic retinopexy)
67113 Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens
Extraocular Muscles
67311 Strabismus surgery, recession or resection procedure; 1 horizontal muscle
67312 Strabismus surgery, recession or resection procedure; 2 horizontal muscle
67314 Strabismus surgery, recession or resection procedure; 1 vertical muscle
67316 Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique)
67318 Strabismus surgery, any procedure, superior oblique muscle
✚ 67320 Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for primary procedure)
✚ 67335 Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s)
Eyelid
67800 Excision of chalazion; single
67801 Excision of chalazion; multiple, same lid
67805 Excision of chalazion; multiple, different lids
Tarsorrhaphy
67875 Temporary closure of eyelids by suture (eg, Frost suture)
Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion, Entropion)
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approachlepharoptosis, Lid Retraction, Ectropion, Entropion)
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
67908 Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator resection
Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion, Entropion)
67914 Repair of ectropion; suture
67915 Repair of ectropion;thermocauterization
67916 Repair of ectropion; excision tarsal wedge
67917 Repair of ectropion; extensive (eg, tarsal strip operations)
67921 Repair of entropion; suture
67922 Repair of entropion;thermocauterization
67923 Repair of entropion; excision tarsal wedge
67924 Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation)
68810 Probing of nasolacrimal duct, with or without irrigation;
68811 Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia
68815 Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent
68816 Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation
Medycoding Notes :
Surgery Notes 1
Dermatochalasis is a condition where there is excess skin and muscle in the eyelids.
Surgical Treatment of Dermatochalasis are :
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Blepharoplasty : The surgeon makes an incision along the natural crease of the eyelid, removes excess skin, and possibly some underlying fat or muscle. The incision is then closed with sutures.
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Canthopexy/Canthoplasty: Procedures to tighten the lower eyelid, often performed alongside lower blepharoplasty to prevent ectropion (outward turning of the eyelid).
What are the code selection criteria for Blepharoplasty ?
The code selection criteria is based on the
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The eyelid where procedure is perform like upper or lower eyelid.
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Is excessive skin in resected or not.
Example 1 : Quick Coding
Dx: Dermatochalasis
Tx: Blepharoplasty of Upper eyelid with excessive skin weighting down lid.
Coding Short description
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Amount of skin and obricularis muscle are measure that is going to be excised.
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Laser was used to create incision and flap removed.
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Nasal Fat excised.
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Suture done
AAPC : Blepharoplasty- Reconstruction Eyelid- Upper- 15822,15823
CPT : 15823 Blepharoplasty, upper eyelid;with excessive skin weighting down lid.
Notes: The upper eyelid orbital fat consists of two fat pads: the nasal, or medial fat pad and the central, or preaponeurotic, fat pad.
Surgery Notes 2
Cataract is a the clouding of the lens,which is typically clear.
Surgical Treatment of Cataract are :
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Phacoemulsification : This is the most common method of cataract surgery. A small incision is made in the cornea, and a device that emits ultrasonic waves is used to break up (emulsify) the cloudy lens into tiny pieces. These pieces are then suctioned out of the eye. After removing the cataract, the surgeon inserts an artificial intraocular lens (IOL) into the remaining lens capsule.
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Extracapsular Cataract Extraction (ECCE): In cases where the cataract is too dense for phacoemulsification, ECCE may be performed. A larger incision is made in the cornea, and the cloudy lens is removed in one piece. The remaining lens capsule is left in place to hold the artificial lens, which is then inserted.
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Intracapsular Cataract Extraction (ICCE): This older technique involves removing the entire lens, including the capsule, through a large incision. An intraocular lens is then placed in a different location, usually in front of the iris (anterior chamber) rather than in the lens capsule.
What are the code selection criteria for Cataract extraction?
The code selection criteria is based on the
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Intracapsular Extraction or Extracapsular
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Simple or Complex
Example 1 : Quick Coding
Dx: Nuclear sclerotic cataract
Tx: Phacoemulsification with intraocular lens implant
Coding short description
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Wire Eyelid Speculum Placed.
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Paracentesis done
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Injected Lidocaine
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Corneear Incision using Keratome blade.
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Circular Capsulorrhexis performed.
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Cortical cleaving hydrodissection was completed
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In-situ phacoemulsification of the lens nucleus and epinuclear material was performed.
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Residual cortical material removed.
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A new Lens implanted .
AAPC : Cataract Eye- Extraction- Extracapsular- 66984, 66988
CPT : 66984 [Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation ]
Notes: Since no any condition is applicable for complex so we will code 66984.
Surgery Notes 3
Glaucoma is a group of eye diseases that damage the optic nerve, which is critical for good vision. This damage is often caused by abnormally high pressure in the eye, although glaucoma can also occur with normal eye pressure.
Surgical Treatment of Glaucoma are :
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Trabeculectomy : This is a standard surgery for glaucoma that lowers pressure inside the eye when medical treatments or laser surgery have failed to bring the eye pressure low enough. In this operation, a small hole is made in the wall of the eye, and a “trapdoor” or “flap” is created over this hole to allow fluid to escape the eye in a controlled fashion. The fluid is shunted from inside the eye, bypassing the obstructed trabecular meshwork, through the small hole and “trapdoor,” while remaining underneath the outer clear membrane of the eye (conjunctiva). This forms a small blister or “bleb” underneath the upper eyelid. Normally, no one will be able to see the “bleb” just by looking at the eyes
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Glaucoma Drainage Devices (Shunts): Drainage implants or tubes (such as the Ahmed or Baerveldt shunt) are placed in the eye to help drain aqueous humor. These devices help direct the fluid to a reservoir (bleb) that forms under the conjunctiva, where it is absorbed.
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Cyclophotocoagulation: A laser is used to target and partially destroy the ciliary body (which produces aqueous humor), reducing fluid production and lowering IOP.
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Laser Iridotomy:Performed primarily for angle-closure glaucoma. A small hole is created in the iris to allow fluid to flow more freely between the anterior and posterior chambers of the eye.
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Trabeculotomy or Goniotomy (for Children) : These are surgeries specifically used for congenital glaucoma. In both techniques, the surgeon opens the trabecular meshwork to help the fluid drain out more easily. Goniotomy requires a clear cornea and is performed under gonioscopic visualization, while trabeculotomy is used when the cornea is cloudy.
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Minimally Invasive Glaucoma Surgery (MIGS): This is less invasive procedures that lower IOP by improving aqueous humor drainage.These are often performed at the same time as cataract surgery. Common MIGS devices and techniques include:
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iStent: A tiny stent placed in the trabecular meshwork to improve drainage.
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GATT (Gonioscopy-Assisted Transluminal Trabeculotomy): A procedure that opens the drainage channels inside the eye without external incisions.
What are the code selection criteria for Glaucoma surgery?
The code selection criteria is based on the
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Placement of Filtration implant that is known as Aqueous shunt
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The way of drainage such as trabeculeocmty , iridectomy or desturction of Ciliary body.
Example 1 : Quick Coding
DX: Severe primary open-angle glaucoma, right eye
Tx: Trabeculectomy with Ex-PRESS P50 shunt and mitomycin C, 3 minutes, right eye
Coding short description
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A wire lid speculum was inserted and the microscope placed.
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A 7-0 Vicryl suture was then placed through the peripheral clear cornea and used to rotate the eye down to isolate superior nasal quadrant where the conjunctiva was entered with Vannas scissors at the limbus.
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Subconjuctival incision was carried.
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Trapezoidal scleral flap which was dissected towards the limbus.
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Mitomycin injected.
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Paractensis performed
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Shunt placed on Anterior chamber and then scleral Flap Closed.
AAPC : Glaucoma- Filtration Implant- Placement- 66180, 66183
CPT : 66183 [Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach]
Notes: Ahmed valve is the example of aqueous drainage device for glaucoma.
Example 2 : Quick Coding
DX: Fibrovascular ingrowth into valve chamber of Ahmed GDD OD
Tx: Glaucoma Drainage Device Revision (Removal of Ahmed FP7 and placement of Baerveldt 250 mm2 GDD superiortemporal sulcus) of the Right Eye
Coding short description
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A superotemporal fornix incision.
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Ahmed tube and reservoir visualised.
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Mini-Wescott scissors were used to dissect the reservoir Tube also removed
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Baerveldt 250 mm2 implant was inserted and sutured
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2 venting slits were made in the extraocular portion of the tube.
AAPC : Glaucoma- Filtration Implant- Revision- 66184, 66185
CPT : 66184 [ Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft]
Notes: Baerveldt valve is the another example of aqueous drainage device for glaucoma.
Surgery Notes 4
Esotropia is a type of strabismus (eye misalignment) where one or both eyes turn inward toward the nose. This condition is commonly referred to as "crossed eyes.
Exotropia is a type of strabismus (eye misalignment) where one or both eyes turn outward, away from the nose. It is often referred to as "wall-eyed" or "divergent strabismus."
Hypertropia is a type of strabismus (eye misalignment) in which one eye is positioned higher than the other.
Surgical Treatment of strabismus are :
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Recession : The surgeon weakens an overactive eye muscle by detaching it from its original position and reattaching it further back on the eye. This reduces the muscle’s pulling power, allowing the eye to move outward more freely.
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Resection : In this technique, the surgeon strengthens a weak muscle by shortening it. A portion of the muscle is removed, and the shortened muscle is reattached, increasing its pulling strength.
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Adjustable Suture Technique: In this technique, the surgeon places sutures on the eye muscles but leaves them adjustable for a few hours after surgery.
What are the code selection criteria for Strabismus surgery?
The code selection criteria is based on the
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Muscle : Vertical and Horizontal.
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Adjustable suture
Surgery Notes 5
Glaucoma is a group of ey
Surgical Treatment of Glaucoma are :
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Trabeculectomy : This
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Glaucoma Drainage Devices (Shunts): Drainag
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Cyclophotocoagulation: A las
What are the code selection criteria for Glaucoma surgery?
The code selection criteria is based on the
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Intracapsular Extraction or Extracapsular
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Simple or Complex
Example 1 : Quick Coding
DX: Severe prim
Tx: Trabeculectom
Coding short description
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A wire lid speculum was inserted and the microscope placed.
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A 7-0 Vi
AAPC : Glaucoma-
CPT : 66183 [Insertion of ah]
Notes: Ahmed valve is the e