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2025 CPT code 65436

Removal of corneal epithelium with application of a chelating agent (e.g., EDTA).

Refer to the current CPT and payer-specific coding guidelines for appropriate use of this code. Do not report code 69990 in addition to codes 65091-68850.

Modifiers may apply depending on the circumstances of the procedure. Consult the CPT guidelines and payer-specific instructions for appropriate modifier usage.Modifiers such as 50 (bilateral procedure) or 51 (multiple procedures) could apply.

Medical necessity is established when the patient has a corneal epithelial defect that is causing significant symptoms (pain, discomfort, impaired vision) and is not responsive to conservative treatment.The procedure is considered medically necessary to alleviate symptoms and promote healing.

The ophthalmologist or other qualified eye care professional is responsible for performing the procedure, including patient preparation, anesthesia, epithelium removal, application of the chelating agent, and post-operative care.

IMPORTANT:65435 (Removal of corneal epithelium; with or without chemocauterization; abrasion, curettage) is a related code that may be used if chemocauterization is also performed.Note that code 69990 should not be reported in addition to codes 65091-68850.

In simple words: The doctor removes the outer layer of the cornea (the clear front part of the eye) and uses a special solution to clean the area. This helps treat certain eye problems and promote healing.

This procedure involves the removal of the corneal epithelium, the outermost layer of the cornea. A chelating agent, such as ethylenediaminetetraacetic acid (EDTA), is applied to remove any remaining cellular debris or deposits from Bowman's layer.The procedure is performed after appropriate patient preparation and anesthesia.The corneal epithelium is separated from its surrounding structures using a surgical knife or sponge, and then removed from the anterior limiting lamina. The chelating agent is then applied to thoroughly clean the area.

Example 1: A patient presents with recurrent corneal erosions.The physician performs a removal of corneal epithelium with application of EDTA to smooth the surface and promote healing., A patient has undergone corneal transplantation and has persistent epithelial defects. The surgeon performs 65436 to remove the damaged epithelium and facilitate re-epithelialization., A patient presents with superficial corneal dystrophy causing significant discomfort. The doctor performs 65436 to remove the abnormal epithelium and improve visual acuity.

Preoperative assessment including visual acuity, slit-lamp examination documenting the extent of the epithelial defect, and confirmation of patient consent. Intraoperative notes detailing the technique used for epithelium removal, the type and amount of chelating agent used, and any complications encountered. Postoperative notes including visual acuity, slit-lamp examination to assess healing, and any post-operative complications.

** Payment for the EDTA chelating agent is generally included in the reimbursement for CPT code 65436.Separate billing for the EDTA is usually not allowed.Always refer to payer-specific guidelines for the most up-to-date billing information.

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