2025 CPT code 65756
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Surgery Feed
Keratoplasty (corneal transplant); endothelial.
Modifiers may be applicable depending on the circumstances, such as bilateral procedures (modifier 50), multiple procedures (modifier 51), or assisting surgeons (modifier 80).
Medical necessity is established by the presence of corneal endothelial dysfunction leading to significant visual impairment that cannot be effectively managed with conservative treatments. Documentation should support the diagnosis and the clinical indication for endothelial keratoplasty.
The ophthalmologist is responsible for performing the entire procedure, including patient preparation, donor graft preparation (if not done separately by a technician), surgical technique, and post-operative care.
In simple words: This is a type of corneal transplant where only the innermost layer of the cornea (the endothelium) is replaced with healthy tissue from a donor.This helps to restore clear vision.
This procedure involves replacing the diseased inner layer of the cornea (endothelium) with healthy donor tissue.The diseased endothelium is removed, and a donor graft containing healthy endothelium, Descemet's membrane, and sometimes a thin layer of stroma, is implanted. Several techniques exist, including DMEK, DSEK, and DSAEK, each varying in the thickness and preparation of the donor graft.The procedure aims to restore corneal transparency and improve vision.
Example 1: A 60-year-old patient with Fuchs' endothelial dystrophy, causing significant corneal edema and blurry vision, undergoes DMEK endothelial keratoplasty. Code 65756 is used to bill for the replacement of the diseased endothelium., A 75-year-old patient with pseudophakic bullous keratopathy following cataract surgery experiences corneal swelling and vision impairment.A DSAEK procedure is performed, and code 65756 is utilized to reflect the replacement of the diseased endothelium with a donor graft., A 55-year-old patient who has undergone a previous corneal transplant experiences graft failure due to endothelial rejection. An endothelial keratoplasty using a DSEK technique is performed. Code 65756 is reported for the transplantation.
Complete ophthalmologic examination, including visual acuity measurements before and after surgery.Detailed operative notes specifying the surgical technique employed (DMEK, DSEK, or DSAEK).Documentation of donor tissue preparation (if performed by the surgeon).Post-operative visual acuity and any complications.Preoperative imaging, such as corneal pachymetry and endothelial cell count.
** The preparation of the donor graft may be reported separately using code 65757 if performed by the surgeon.The specific technique used (DMEK, DSEK, DSAEK) should be documented in the operative report and may influence the overall reimbursement.
- Payment Status: Active
- Modifier TC rule: The TC modifier may not be directly applicable to this code as it pertains to the professional component of the surgical procedure.The professional and technical components are usually bundled together for this CPT code.
- Specialties:Ophthalmology
- Place of Service:Ambulatory Surgical Center, Outpatient Hospital, Inpatient Hospital