CPT Eye, Ocular, Adnexa, Auditory System

CPT GUIDELINES
EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE

EYE AND OCULAR ADNEXA (65091 – 68899)

FORMAT:

• The Eye and Ocular Adnexa subsection (65091-68899) includes the subheadings Eyeball, Anterior Segment, Posterior Segment, Ocular Adnexa, and Conjunctiva.

• There are the typical incision, excision, repair, and destruction categories but also some that are unique.

For example, the subheading Eyeball includes categories for both Removal of Eye (65091-65114) and Removal of Foreign Body (65205- 65265), although you would expect to find all removal codes in a removal category.

NOTE: Remember to use modifier -50 (bilateral procedure) when the procedure is performed on both eyes. Modifiers -RT and -LT may be assigned for bilateral procedures of anatomic sites that are in pairs; i.e., eyes, breasts, legs, arms, etc.

• In this section are codes that include previous surgery to the eye. For example, in the subheading Ocular Adnexa, 67331 is reported for patients undergoing strabismus surgery who have had previous eye surgery or injury.

• Also, the category Prophylaxis (preventive treatment) (67141, 67145), under the subheading Posterior Segment, has notes regarding the assignment of these codes.

• The Prophylaxis codes include all the sessions in a treatment period. The Destruction codes in this subcategory include “one or more sessions.”

• Read the code descriptions carefully so you know which elements are included in the code because what is or is not included in the code descriptions varies greatly.

EYEBALL (65091 – 65290)

Removal of Eye (65091 – 65290)

• The Removal of Eye category contains codes to report evisceration, which is removal of the contents of the globe while leaving the extraocular muscles and sclera intact (65091, 65093); enucleation, which is removal of the eye while leaving the orbital structures intact, (65101-65105); and exenteration, which is removal of the eye, adnexa, and part of the bony orbit (65110-65114).

• The codes in the Removal of Eye category are divided based on which of these procedures was performed, if an implant was inserted, and in the case of the exenteration, if the bony orbit was removed or a muscle or myocutaneous flap was performed.

• These codes do not report skin grafting to the orbit. When the operative report indicates skin grafting, report the service separately with codes from the Integumentary System (15120/15121 or 15260/15261). If the eyelid was repaired deeper than skin level, refer to the reconstruction codes 67930/67935 (partial or full thickness repair).

Secondary Implants(s) Procedures (65125 – 65175)

• Implants may be placed inside the muscular cone (ocular implant or fake eye) or outside the muscular cone (orbital implant).

• The ocular implant is the artificial eye, and the orbital implant replaces the orbit that was occupied by the eyeball before removal. With some implants, the muscles are attached to the implant to enable the artificial eye to move and thus appear more natural.

• The codes in the 65125-65155 range report a subsequent implantation of ocular implants based on the type of service provided with the implant, such as grafting or attachment of muscles to implant. • Removal of an ocular implant is reported with 65175.

• An orbital implant is a cosmetic device that covers the outer portion of the eye and is also known as a scleral shell prosthesis. Orbital implant insertion is reported with 67550 and removal with 67560.

Removal of Foreign Bodies (65205 – 65265)

• The removal codes are for foreign bodies that are located in the external eye or the intraocular eye.

• A slit lamp is a low powered microscope with a high-intensity light source that focuses the light as a long narrow beam (slit) and is used to examine eyes

• Note that the only difference between 65220 and 65222 is whether a slit lamp is or is not utilized.

Repair of Laceration (65270 – 65290)

• The repair codes are assigned to report laceration repair based on where the laceration is located (conjunctiva, cornea, and/or sclera).

• Code 65286 reports the application of tissue glue for a perforation of the eyeball.

ANTERIOR SEGMENT (65400 – 66999) Cornea (65400 – 65785)

• The cornea is the transparent part of the eye.

• The cornea may be the site of a superficial lesion that is completely removed and reported with 65400.

• If only a portion of the corneal lesion was removed for pathology analysis, report the service as a biopsy with 65410.

• A keratoplasty is repair of the cornea. Codes 65710-65756 report keratoplasty based on the type of procedure performed and include grafts and preparation of donor material. A penetrating keratoplasty (65730-65755) is the removal of the full thickness of the cornea and replacement with donor cornea. A lamellar keratoplasty (65710) is a procedure in which only a thin layer of the cornea is removed and replaced with donor cornea.

• Aphakia is absence of the lens of the eye, and pseudophakia is the presence of an artificial lens after cataract surgery. These terms are in three of the keratoplasty code descriptions.

ANTERIOR SEGMENT (65400 – 66999) Anterior Chamber (65800 – 66030)

• The anterior chamber of the eye is a fluid-filled (aqueous humor) space, located behind the cornea and in front of the iris. The categories of Incision (65800-65880), Removal (65900-65930), and Introduction (66020-66030) are for procedures performed on the anterior chamber of the eye.

• Paracentesis is the removal of fluid. When a physician performs paracentesis of the anterior chamber of the eye, a needle is inserted into the anterior chamber and fluid is withdrawn. The fluid may be withdrawn for diagnostic purposes (65800) or for therapeutic purposes (65810-65815). If an injection procedure is also performed, report 66020 or 66030.

• Goniotomy (65820) is a surgical procedure that utilizes an instrument called a goniolens. This procedure may be performed for congenital glaucoma, a condition in which the optic nerve at the back of the eye may be damaged and cause a loss of vision, especially peripheral vision. A note following code 65820 directs the coder not to use modifier -63 (procedure performed on infants less than 4 kg) with the code.

• Codes for severing adhesions or scar tissue from the anterior chamber of the eye are based on the location of the adhesion or scar tissue (65860-65880). Posterior synechiae are adhesions of the iris to the lens of the eye, and anterior synechiae are adhesions of the iris to the cornea. Severing of the adhesions is performed using either laser (66821) or incisional technique.

Anterior Sclera (66130 – 66250)

• The sclera is the white, fibrous outer layer of the eyeball and the anterior sclera is the front part of the eye. The anterior sclera may be the site of lesions that are excised (66130) by incision of the conjunctiva to gain access to the lesion. Depending on the size of the lesion, the area of the sclera may not require sutures.

• Sometimes, the flow of the aqueous humor is not absorbed or too much fluid is produced, and a surgeon may perform a fistulization (creation of a passage) of the sclera to decrease the pressure.

• The fistulization can be created by means of removal of a portion of the sclera and iris (e.g., 66150), thermocauterization (e.g., hot probe, 66155), or punch or scissor removal (e.g., 66160).

• A trabeculotomy ab externo or trabeculectomy ab externo (e.g., 65850, 66170, 66172) is a surgical procedure in which the trabecular meshwork (iris-scleral junction, drains aqueous humor) is reshaped or punctured. This procedure may be performed as a treatment for glaucoma.

Iris, Ciliary Body (66500 – 66770)

• The ciliary body is located behind the iris (colored part of the eye) and produces aqueous humor.

• The smooth muscle of the ciliary body attaches to the lens. An iridectomy is usually performed for removal of a lesion (66600) or as a treatment for glaucoma (66625, 66630) by creation of an opening to drain aqueous humor. If the iridotomy/iridectomy is performed by means of laser, report the procedure with 66761.

• If an iridoplasty is performed by means of photocoagulation, report the procedure with 66762.

othrombin time, coagulation time, or hemogram.

Lens (66820 – 66940)

• A common procedure performed on the lens of the eye is cataract removal. Cataract removal and lens replacements (66830-66990) utilize one of two different approaches or techniques:

• Extracapsular cataract extraction (66984) (ECCE) is partial removal of the capsule and is the most common method. It removes the hard nucleus of the lens in one piece and the soft cortex in multiple pieces. The posterior lens capsule is left in place.

• Intracapsular cataract extraction (66983) (ICCE) is the removal of the lens and surrounding lens capsule, which removes the cataract in one piece.

• Today, most cataract surgery is performed using phacoemulsification, which dissolves the hard nucleus by ultrasound, then removes the soft cortex in multiple pieces.

Ocular Adnexa (67311 – 67999) Extraocular Muscles (67311 – 67399)

• Under the subheading of Ocular Adnexa are codes for strabismus surgery,

which corrects muscle misalignment. The codes are divided based on repair

of vertical (67314, 67316) or horizontal (67311, 67312) muscles and are reported

by the number of muscles repaired. Vertical muscles move the eye up and down,

while the horizontal muscles move the eye side to side. Orbit (67400 – 67599)

• Under the subheading Orbit are codes for orbitotomy and fine needle aspiration. The orbitotomy codes are divided based on the approach and if a bone flap was or was not placed. Orbitotomy that is performed without a bone flap and with either a frontal or transconjunctival approach is reported with codes 67400-67414.

• Orbitotomy performed with a bone flap and with a lateral approach is reported with codes 67420-67450. The codes for a transcranial orbitotomy are located in the Nervous System subsection (61330-61333). Within the Orbit subheading there is also a code (67415) for fine needle aspiration of the orbital contents, and it is usually performed as a biopsy method for an orbital mass.

Ocular Adnexa (67311 – 67999)

Eyelids (67700 – 67999)

• The Eyelids subheading includes procedures performed by incision, excision, destruction, and tarsorrhaphy (suturing the eyelids together).

There are also codes to report eyelid repair and reconstruction.

Eyelid repairs include ectropion (outward sagging/turning, 67914-67917) and entropion (inward turning, 67921-67924).

• HCPCS modifiers are added to the procedure code to indicate the specific eyelid.

Conjunctiva (68020 – 68899)

• The Conjunctiva subheading includes Incision and Drainage (68020, 68040), Excision and/or Destruction (68100- 68135), Injection (68200), Conjunctivoplasty (68320-68340), and the Lacrimal System (68400- 68850).

• Conjunctivoplasty (68326-68328) involves reconstruction of the cul-de-sac with a conjunctival graft or rearrangement.

• Lacrimal System procedures includes incision, excision, repair, and probing. The most common procedure performed is nasolacrimal duct probing generally due to an obstruction and reported with 68810 or 68811.

AUDITORY SYSTEM (69000 - 69979)

FORMAT

• The Auditory System subsection (69000-69979) is divided into the subheadings External Ear, Middle Ear, Inner Ear, and Temporal Bone, Middle Fossa Approach.

• The first three subheadings represent the anatomic divisions of the auditory system: external, middle, and inner ear.

• The categories listed under each subheading include introduction, incision, excision, removal, repair, and other procedures, depending on the particular subheading.

EXTERNAL EAR (69000 – 69399)

Incision (69000 – 69090)

• The external ear may be the site of an abscess or hematoma, and the incision and drainage may be simple (69000) or complicated (69005).

• If the abscess drained is within the auditory canal, report the service with 69020. Be careful when reporting 69020 as it can be bundled into a major procedure and not reported separately. Excision (69100 – 69155)

• Codes for the external ear include biopsy by location of external ear (69100) or external auditory canal (69105), excision of the external ear, either partially or complete (69110, 69120). If the external ear was reconstructed after the excision, report the repair with split thickness autograft codes (15120, 15121) from the Integumentary System based on the square centimeters used in the repair.

• Exostosis is a bony growth and when present in the external auditory canal, it is termed “surfer’s ear,” because it is associated with chronic cold-water exposure. An incision is made behind the ear to gain access to the canal, and the bony growth is excised (69140).

EXTERNAL EAR (69000 – 69399)

Removal of Foreign Bodies (69200 – 69222)

• With the shape of the ear, it is easy to see how foreign bodies and cerumen (earwax) can become lodged in the external ear. When a foreign body is removed from the ear, the code reported is based on whether general anesthesia was or was not used (69200, 69205).

• Ear lavage (69209) is the unilateral removal of impacted cerumen (ear wax) using irrigation/lavage. Removal of the cerumen with instrumentation is reported with 69210 (if bilateral then append with modifier -50).

Repair (69300 – 69320)

• An otoplasty is a procedure performed for a protruding ear that may or may not include a decrease in the size of the ear. This procedure is usually performed with the use of conscious sedation, which is included in 69300. When an otoplasty is performed bilaterally, modifier -50 is added to code

• Reconstruction of the external auditory canal (canalplasty/canaloplasty) may be performed for conditions such as stenosis due to injury or infection (69310) or for a congenital defect (69320). Canaloplasty is bundled into some middle ear repair codes, such as 69631-69646 and not reported separately.

MIDDLE EAR (69240 – 69799)

Myringotomy & Tympanostomy

• The eustachian tube connects the middle ear to the back of the throat and allows for drainage of fluid. When a eustachian tube dysfunctions, fluid collects in the middle ear. The tube can also become inflamed from allergies or infection.

• Eustachian tube dysfunction is a fairly common condition in children, because the tube does not always mature to the level of normal function and therefore does not function properly. The fluid or inflammation prevents air from entering the middle ear, resulting in a pressure increase in the middle ear.

• Surgical intervention is an inflation of the eustachian tube with access through the nose (transnasal).

MIDDLE EAR (69240 – 69799)

Myringotomy & Tympanostomy

• Myringotomy is the incision into the tympanic membrane (69420, 69421) and reinflation of the eustachian tube.

• Tympanostomy is the insertion of a small plastic or metal tube (PE [pressure equalization] tube) that allows the fluid to drain (69433, 69436). The tubes may later be removed, fall out naturally, or sometimes be left in place.

• Surgical removal of a ventilation tube is reported with 69424, which is a procedure that requires general anesthesia. Ventilation tube removal is bundled into many major procedures, in which case the removal is not reported separately.

MIDDLE EAR (69240 – 69799)

Note: Code 69424 is unilateral, so if the tubes were removed

bilaterally, add modifier -50.

Excision (69501- 69554)

• Middle ear excision procedures include antrotomy (simple mastoidectomy, 69501), mastoidectomy (complete, modified radical, or radical, 69502-69511), polyp removal (69540), and tumor removal (69550-69554).

• Also included in the Excision category is a petrous apicectomy. The petrous apex of the temporal bone may be the site of infection (petrous apicitis) that can lead to more complicated infection, such as brain abscess or meningitis. Sometimes, to remove the infected bone, a mastoidectomy is performed and is included in the petrous apicectomy code 69530.

Repair (60601 – 69676)

• Middle ear repair procedures include revision mastoidectomies based on the extent of the procedure. For example, a simple mastoidectomy is performed on a patient with cholesteatoma of the middle ear.

• A cholesteatoma is a benign growth of skin in an abnormal location, in this case in the middle ear. The growth may reoccur, and the surgeon may perform a complete mastoidectomy (69601). If the disease has progressed to the point where the tympanic membrane is damaged and requires repair, the procedure is reported with 69604.

• The two major divisions in the tympanoplasty codes are with or without removal of the mastoid bone (mastoidectomy).

• When no mastoidectomy is performed, choose the code from the 69631-69633 range, based on the extent of the procedure. When a mastoidectomy is performed, report the service with codes from the 69641-69646 range, based on the extent of the procedure.

• The ossicular chain is the bones of the ear that include the malleus (hammer), incus (anvil), and stapes (stirrup). The chain may be eroded and repaired as a part of a tympanoplasty (69632 or 69642).

• The repair may be so extensive that it may require the use of prosthesis, such as a partial ossicular replacement prosthesis (PORP, incus and malleus are absent or damaged) or total ossicular replacement prosthesis (TORP, incus and arch of the stapes are damaged, or the malleus, incus and arch of the stapes are absent).

• PORP and TORP are reported with 69633 or 69637, depending upon other repairs performed during the tympanoplasty.

INNER EAR (69801 – 69949)

Incision &/or Destruction (69801 – 69806)

• A labyrinth is a cavelike structure, located in the inner ear. The labyrinth is dominated by two fluid-filled spaces that contain endolymph and perilymph. These spaces contain the nerve tissue responsible for hearing and balance. When the pressure within the space is altered, vertigo, ringing in the ears, and hearing loss may occur.

• A labyrinthotomy is a procedure in which the labyrinth is surgically incised and various procedures performed to return the labyrinth to functional condition. Code 69801 is reported for a labyrinthotomy. Excision (69905 – 69915)

• A labyrinthectomy is a procedure in which the incus and stapes are removed. If a transcanal approach is used, report 69905. If a postauricular incision (behind the ear) is used as the approach, report 69910.

INNER EAR (69801 – 69949)

Introduction (69930)

• A cochlear device implant is a computerized device that restores partial hearing in those who are profoundly hearing impaired. A receiver on the outside of the skin behind the ear picks up sound waves. The receiver is placed over the transmitter, which is surgically implanted under the skin behind the ear. A sound processor is connected to an electrode implanted between the processor and the cochlea, and it receives a signal from the transmitter and transfers the signal to the cochlear nerve. The implantation of the cochlear device is reported with 69930.

Temporal Bone, Middle Fossa Approach (69950 – 69979)

• The middle fossa approach is used by surgeons to excise acoustic neuromas, to decompress the facial nerve (proximal temporal), and repair nerves in the vestibular labyrinth.

• The codes in the Temporal Bone, Middle Fossa Approach subheading report removal of the vestibular nerve (69950), relief of pressure (decompression) of the facial nerve and/or repair (69955), decompression of the internal auditory canal (69960), and removal of tumors of the temporal bone (69970).

OPERATING MICROSCOPE (69990)

• An operating microscope is used in microsurgical procedures

and is reported separately with add-on code 69990,

unless the code indicates the inclusion of use of an operating microscope.

This does not include magnifying loupes that are used to enlarge the

area being viewed. • This code is an add-on code and is never reported

alone; rather, it is reported with the procedure in which the operating

microscope was used. Code 69990 is assigned with codes from any

subsection within the Surgery section.

***END OF NOTES***

CPT GUIDELINES EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE

CPT GUIDELINES
EYE, OCULAR ADNEXA, AUDITORY, AND OPERATING MICROSCOPE