Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist performed a pterygium excision with an amniotic graft. But I'm not sure which code to report -- 65426 describes the pterygium excision, but CPT 65780 describes the membrane transplantation. Can I report both?

Washington Subscriber

Answer: Report 65780 (Ocular surface reconstruction; amniotic membrane transplantation) alone. The Correct Coding Initiative bundles that code with 65426 (Excision or transposition of pterygium; with graft). If you attempt to bill both codes separately, your carrier will pay only 65426. In this case, the pterygium removal is part of the ocular surface reconstruction.

Although 65426 may also generally describe the procedure, CPT introduced 65780-65782 in 2004 specifically to describe ocular surface reconstruction using stem cells obtained from living or non-living donor grafts. Medicare will also reimburse more for 65780 (20.48 facility RVUs) than for 65426 (10.89 facility RVUs).

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