CPT Code 65400

CPT code 65400 is the medical billing code for the surgical removal of an eye lesion.

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What is CPT Code 65400

CPT code 65400 is used for the surgical removal of a lesion from the eye, specifically from the cornea, sclera, or conjunctiva. This procedure is typically performed by an ophthalmologist to address abnormalities that may be causing discomfort or impairing vision.

Does CPT 65400 Need a Modifier?

For CPT code 65400, which pertains to the excision of a lesion of the cornea (except pterygium), several modifiers may be applicable depending on the specific circumstances of the procedure. Here is an ordered list of potential modifiers and the reasons for their use:

1. -RT (Right Side) and -LT (Left Side): These modifiers are used to indicate which eye the procedure was performed on. Since the procedure involves the eye, specifying the laterality is crucial for accurate billing and medical records.

2. -50 (Bilateral Procedure): If the procedure is performed on both eyes during the same operative session, this modifier should be used. It is important for reimbursement purposes as some payers may adjust the payment for bilateral procedures.

3. -22 (Increased Procedural Services): This modifier is used when the work required to perform the procedure is substantially greater than typically required. Documentation must support the extra work, such as increased complexity or time spent.

4. -52 (Reduced Services): If the procedure is partially reduced or eliminated at the physician’s discretion, this modifier should be applied. It indicates that a service or procedure was partially reduced without changing the basic character of the service.

5. -59 (Distinct Procedural Service): This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This can be crucial in cases where multiple procedures are performed on the same eye but are unrelated.

6. -51 (Multiple Procedures): Used when multiple procedures are performed during the same surgical session. It helps to indicate that multiple procedures were performed, and it may affect reimbursement rates.

7. -76 (Repeat Procedure by Same Physician): This modifier is used if the procedure had to be repeated in the same session by the same physician. It can be relevant in scenarios where the initial excision was not sufficient, and a repeat was necessary.

8. -78 (Unplanned Return to the Operating/Procedure Room): Used when a patient returns to the operating or procedure room for a related procedure during the postoperative period. This could be applicable if complications arise necessitating further immediate intervention.

Each of these modifiers provides specific information that can affect billing and reimbursement, and their correct application is crucial for accurate healthcare revenue cycle management.

CPT Code 65400 Medicare Reimbursement

CPT code 65400, which pertains to the excision of a lesion of the cornea (e.g., dermoid, pterygium), is generally reimbursable by Medicare. However, the reimbursement for this procedure can vary based on several factors including the geographic location of the service provider, the setting in which the procedure is performed (such as hospital outpatient department versus an ambulatory surgical center), and the specifics of the Medicare plan.

To determine the exact reimbursement amount for CPT code 65400 under Medicare, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) available on the Centers for Medicare & Medicaid Services (CMS) website. This schedule provides detailed information on the reimbursement rates for various procedures based on the locality. Additionally, it is important to ensure that the documentation supports the medical necessity of the procedure, as this is a critical factor in securing reimbursement from Medicare.

Providers should also be aware of any potential updates or changes in Medicare policies regarding ophthalmological services to ensure compliance and accurate billing.

Are You Being Underpaid for 65400 CPT Code?

Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately detecting underpayments. With the capability to read your contracts and identify discrepancies down to specific CPT codes, such as 65400 for the removal of an eye lesion, RevFind ensures that every payment reflects your contracted rates. Schedule a demo today to see how RevFind can help secure the payments you are owed by each individual payer.

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