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CODING 65426 OR 65780

Donna Posted Wed 16th of January, 2013 14:40:12 PM

in your ask the coder questions you say to code 65780 for pterygium with amnion graft, but according to the AAO, you should use 65426 if you are only doing one graft whether self graft or amnio graft. Use 65780 only when you do both autograft and amnion. I don't want to loose money (we have always used 65780) but I want to be correct. Do you have an update or do you stand by you original advice.

SuperCoder Answered Fri 18th of January, 2013 18:54:10 PM

CPT® Assistant June 2009; Volume 19: Issue 6 clearly says:

Ocular Surface Reconstruction

CPT code 65780, Ocular surface reconstruction; amniotic membrane transplantation, was first introduced in CPT codebook 2004. This code was designed for use in severe ocular surface disease in which there is a persistent corneal epithelial defect as well as stromal thinning due to neurotrophic keratopathy, corneal ulcer, or non-healing surgical wounds. This procedure involves debridement of the involved epithelium and stroma followed by the placement and suturing of one or more layers of amniotic membrane over the defect.

There is another surgical service that utilizes amniotic membrane that may lead to some confusion in coding. In some surgical procedures, amniotic membrane is used after the removal of a conjuctival growth known as pterygium graft. In those situations, the correct code to report is 65426, Excision or transposition of pterygium; with graft.

This is in conjunction to what our RQ says

Question: The ophthalmologist wants to perform a pterygium excision with anmiotic membrane graft. A rep told us to report 65780 and V2790 rather than 65426. Is that correct?

Georgia Subscriber

Answer: Yes. If the ophthalmologist is using an amniotic membrane graft (such as AmnioGraft), report 65780 (Ocular surface reconstruction; amniotic membrane transplantation).

Although 65426 (Excision or transposition of pterygium; with graft) may also generally describe the procedure, CPT introduced 65780-65782 in 2004 specifically to describe “ocular surface reconstruction utilizing stem cells obtained from living or non-living donor grafts.” Medicare will also reimburse more for 65780 (20.99 facility RVUs) than for 65426 (10.42 facility RVUs).

The facility should report HCPCS code V2790 (Amniotic membrane for surgical reconstruction, per procedure) for the supply of the donor tissue.

Published in 2006

I hope this helps!

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