2025 CPT code 67400
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Feed
Incision and exploration of the orbit (eye socket) without creating a bone flap, for diagnostic purposes, possibly including tissue biopsy.
Modifiers may be applicable to this code to indicate specific circumstances of the procedure, such as increased procedural services (22), bilateral procedure (50), or reduced services (52).
Medical necessity for 67400 must be supported by appropriate signs and symptoms, such as proptosis, orbital pain, diplopia, or suspected orbital mass or foreign body.Diagnostic imaging findings may further support the medical necessity.
The surgeon prepares the patient and administers anesthesia. An incision is made in the upper eyelid crease (frontal approach) or below the eye (transconjunctival approach). The orbit is examined for abnormalities and a biopsy taken if necessary.The incision is then closed.
In simple words: The doctor makes a small cut near the eye to look inside the eye socket.They might take a small tissue sample if anything looks unusual.
Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy.This procedure involves making an incision in the eyelid area to access the orbit (the bony cavity that holds the eye) without removing any bone. The surgeon explores the orbit to look for abnormalities, such as tumors.If any suspicious tissue is found, a biopsy may be taken for further analysis.
Example 1: A patient presents with proptosis (bulging eye) and suspected orbital tumor.An orbitotomy (67400) is performed to visualize the orbit and biopsy the suspected mass., A patient has experienced trauma to the eye with suspected orbital foreign body. An orbitotomy (67400) is performed to explore the orbit and potentially remove the foreign body, though if specifically for removal, 67413 should be used., A patient has unexplained orbital pain and swelling.An orbitotomy (67400) is performed to explore for any signs of infection or inflammation and to obtain tissue for biopsy if needed.
Documentation should include operative report detailing the surgical approach, findings within the orbit, any biopsies taken, and any other procedures performed. Preoperative and postoperative diagnoses should be clearly documented. The medical necessity for the procedure should be justified with supporting clinical findings.
- Payment Status: Active
- Specialties:Ophthalmology, Oculoplastic Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Physician's Office