2025 CPT code 65400
Effective Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Feed
Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium.
Modifiers are applicable. Modifiers LT and RT should be used to specify which eye was operated on. Other modifiers like 50 (bilateral procedure), 52 (reduced services), and others may be applicable depending on the specific circumstances of the procedure and should be used accordingly.
Medical necessity must be supported by documentation that the corneal lesion significantly impairs vision, causes discomfort, or poses a threat to ocular health. The chosen procedure must be the least invasive option to effectively address the lesion.
The surgeon is responsible for prepping and anesthetizing the patient, examining the eye, identifying and excising the lesion, and dressing the wound post-operatively.
In simple words: This procedure removes a thin layer from the surface of the eye to get rid of a problem area like a scar or abnormal growth, but not a pterygium. The eye is numbed, the surgeon carefully removes the problem area, and a bandage is put on the eye.
This procedure involves the surgical removal of a portion of the cornea to excise a lesion, scar tissue, or other abnormality, but specifically excludes the removal of a pterygium. It is a type of lamellar keratectomy, where a thin layer of corneal tissue is removed. The procedure typically begins with prepping and anesthetizing the patient. The provider then examines the cornea, identifies the lesion, and uses a surgical knife to excise the targeted tissue. The wound is then dressed.
Example 1: A patient presents with a corneal scar resulting from a previous injury. The ophthalmologist performs a lamellar keratectomy (65400) to remove the scar tissue and improve the patient's vision., A patient has a benign corneal lesion that is causing irritation and affecting vision. The ophthalmologist opts to excise the lesion using a lamellar keratectomy approach (65400)., Following a corneal infection, a patient develops an opacity on the cornea. To address this and restore corneal clarity, a lamellar keratectomy (65400) is performed to remove the affected tissue.
Documentation should include the type, size, and location of the corneal lesion, pre-operative examination findings, surgical technique used, and post-operative instructions. Any associated conditions affecting the cornea should also be documented.
- Specialties:Ophthalmology
- Place of Service:Ambulatory Surgical Center, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital