2025 CPT code 65450
(Active) Effective Date: N/A Revision Date: N/A Surgery - Removal or Destruction Procedures on the Cornea Surgical Procedures on the Eye and Ocular Adnexa Feed
Removal or destruction of a corneal lesion using cryotherapy, photocoagulation, or thermocauterization.
Modifiers -LT (Left Side), -RT (Right Side), -50 (Bilateral Procedure), -22 (Increased Procedural Services), -52 (Reduced Services), -59 (Distinct Procedural Service), -76 (Repeat Procedure by Same Physician), and -79 (Unrelated Procedure) may be applicable depending on the circumstances.Refer to the CPT manual for details on modifier usage.
Medical necessity is established by the presence of a corneal lesion impacting the patient's vision or causing discomfort. The chosen method of removal or destruction should be supported by clinical judgment and documented appropriately. Documentation of the lesion's nature, extent, and impact on the patient's visual function or comfort is crucial for demonstrating medical necessity.
The ophthalmologist or qualified healthcare professional is responsible for pre-operative assessment, preparing the patient (including anesthesia), performing the lesion removal or destruction, post-operative care, and appropriate documentation.
- Surgical Procedures on the Eye and Ocular Adnexa
- Surgical Procedures on the Eye and Ocular Adnexa > Surgical Procedures on the Anterior Segment of the Eye > Procedures on the Cornea > Removal or Destruction Procedures on the Cornea
In simple words: The doctor removes or destroys a damaged area on the surface of the eye (cornea) using freezing, a laser, or a heated instrument.This is done to treat a lesion or diseased tissue on the cornea.
This CPT code encompasses the removal or destruction of a corneal lesion using one of three methods: cryotherapy (freezing), photocoagulation (laser), or thermocauterization (heat).The procedure involves preparing and anesthetizing the patient, excising the lesion (if necessary), and then destroying it using the chosen method. Cryotherapy often involves repeated freezing and thawing cycles using a cryoprobe applied to the cornea.The choice of method depends on the nature and location of the lesion and the physician's preference.
Example 1: A patient presents with a corneal ulcer.The physician uses cryotherapy to destroy the infected tissue., A patient has a corneal neovascularization. The physician uses photocoagulation to eliminate the abnormal blood vessels., A patient presents with a pterygium that extends onto the cornea. The physician excises the pterygium and utilizes thermocauterization to ensure complete removal of any remaining abnormal tissue.
Detailed documentation should include the patient's history, visual acuity before and after the procedure, type of lesion, method used for removal/destruction (cryotherapy, photocoagulation, or thermocauterization), number of treatments administered, and any complications or post-operative instructions.Pre-operative and post-operative photographs are typically required.Supporting diagnostic information, such as slit-lamp biomicroscopy findings, should also be documented.
** Accurate coding requires detailed documentation of the lesion's characteristics and the method used for its removal or destruction. Reimbursement varies considerably based on payer, location, and specific circumstances.Always refer to the most current CPT and payer guidelines for accurate coding and billing.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: This information is payer and location specific and varies; consult your local Medicare Administrative Contractor (MAC) for accurate RVU and reimbursement data.
- Global Days : The global period is not explicitly defined for this code; check payer guidelines for specific details.
- Payment Status: Active, but reimbursement varies by payer and location.
- Modifier TC rule: A Technical Component (TC) modifier is not typically applicable to this code, as it represents the physician's work in removing or destroying the corneal lesion.
- Fee Schedule : Historical fee schedule data is unavailable.Consult payer-specific fee schedules for historical information.
- Specialties:Ophthalmology
- Place of Service:Office, Ambulatory Surgery Center, Hospital (Inpatient or Outpatient)