2025 CPT code 68110
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Surgery Feed
Excision of a conjunctival lesion measuring up to 1 cm.
Modifiers may apply depending on the circumstances. For instance, modifier 51 may apply if multiple procedures are performed during the same session.Consult the CPT manual for appropriate modifier usage.
The medical necessity for this procedure is established by the presence of a symptomatic conjunctival lesion impacting vision, causing discomfort, or having cosmetic implications. Documentation of the symptoms and clinical justification for excision must be present.
The ophthalmologist or qualified healthcare professional is responsible for all aspects of the procedure, including patient preparation, anesthesia, surgical excision, and wound closure.
In simple words: The doctor removes a small (up to 1 centimeter) growth on the inside of the eyelid to reduce pain, pressure, and possibly improve vision. This involves numbing the eye, removing the growth, and possibly stitching the area.
This procedure involves the surgical removal of a lesion located on the conjunctiva, the mucous membrane lining the inner surface of the eyelid. The lesion's size is limited to a maximum of 1 cm in diameter.The procedure aims to alleviate pain, pressure, and often improve vision. It typically involves prepping and anesthetizing the patient, placing a lid speculum for examination, using a traction suture at the nasal limbus, employing a corneal light shield to prevent phototoxicity, marking the lesion with a margin of 3-4mm, excising the lesion, and suturing the incision if necessary.This code represents a complete excision, not a biopsy. If only a portion of the lesion is removed for biopsy, code 68100 should be considered instead.
Example 1: A patient presents with a 0.8 cm pterygium on the conjunctiva causing irritation and blurry vision. The ophthalmologist excises the lesion using 68110., A patient has a small (0.5 cm) benign conjunctival nevus that is cosmetically undesirable.The ophthalmologist removes the nevus using 68110., A patient with a history of recurrent conjunctival inflammation has a small, raised lesion (0.9 cm) that is biopsied.However, the entire lesion was removed. 68110 is reported as the entire lesion was removed.
Detailed operative report specifying the size and location of the lesion, the technique used (excision vs. biopsy), and the presence or absence of sutures.Preoperative and postoperative notes should be included.Any pathology report should be attached if applicable.Images of the lesion are helpful for documentation.
** Accurate coding relies heavily on detailed documentation differentiating between excision and biopsy. Ensure that the procedure performed aligns precisely with the definition of excision as opposed to simple removal or biopsy. Review the entire clinical documentation before assigning this code.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: Data unavailable. Consult current fee schedules for RVU and reimbursement information.
- Global Days: Data unavailable. The global period may vary based on payer and other factors.
- Payment Status: Active
- Modifier TC rule: The application of a Technical Component (TC) modifier is not typically applicable to this code.This is because the entire service is usually considered a single unit.
- Fee Schedule: Data unavailable. Consult historical fee schedules for specific reimbursement data.
- Specialties:Ophthalmology
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)