How To Use CPT Code 65778

CPT 65778 involves the placement of amniotic membrane on the ocular surface without sutures for wound healing. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 65778.

1. What is CPT 65778?

CPT 65778 is a medical procedure code that refers to the placement of amniotic membrane on the ocular surface without sutures for the purpose of wound healing. This procedure is used to treat various ocular surface disorders and promote healing by providing a temporary protective barrier and delivering essential growth factors to the affected area.

2. 65778 CPT code description

The official description of CPT code 65778 is: “Placement of amniotic membrane on the ocular surface; without sutures.”

3. Procedure

  1. The eye requiring treatment is prepped and draped in a sterile fashion.
  2. The treatment area is irrigated and cleaned with an antiseptic solution.
  3. Any loose ocular tissue is removed.
  4. Lysis of conjunctival adhesions is performed, removing conjunctival epithelial debris.
  5. The provider excises cicatricial tissues.
  6. A single sheet of amniotic membrane is placed over the ocular surface without sutures. Some amniotic membrane grafts designed for this purpose have “clips” that secure the graft to the eye, which is still considered a sutureless repair.
  7. The provider applies topical antibiotics to the treatment area.

4. Qualifying circumstances

Patients eligible to receive CPT 65778 services are those with ocular surface disorders that require wound healing and tissue repair. These conditions may include persistent epithelial defects, corneal ulcers, chemical burns, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, and other similar disorders. The decision to perform this procedure is based on the provider’s clinical judgment and the patient’s specific needs.

5. When to use CPT code 65778

It is appropriate to bill the 65778 CPT code when the provider performs the placement of amniotic membrane on the ocular surface without sutures for wound healing. This procedure is indicated for patients with ocular surface disorders that require tissue repair and healing. The provider must determine that this treatment is medically necessary and document the rationale for choosing this procedure over alternative treatments.

6. Documentation requirements

To support a claim for CPT 65778, the provider must document the following information in the patient’s medical record:

  • A comprehensive history and physical examination, including the patient’s ocular surface disorder diagnosis and the rationale for choosing the amniotic membrane placement procedure.
  • A detailed description of the procedure performed, including the steps taken, materials used, and any complications encountered.
  • Post-procedure care instructions and follow-up plans, including any additional treatments or interventions required.
  • Documentation of the patient’s response to the procedure and any improvements or changes in their ocular surface condition.

7. Billing guidelines

When billing for CPT code 65778, it is essential to follow specific guidelines and rules to ensure accurate reimbursement. Providers should append modifier 50 if the procedure is performed on both eyes and either modifier RT or LT if the service is rendered on a single eye. If the provider secures the amniotic membrane with sutures, they should use CPT code 65779 instead.

8. Historical information

CPT 65778 was added to the Current Procedural Terminology system on January 1, 2011. The code was changed on January 1, 2014, with the previous descriptor being “Placement of amniotic membrane on the ocular surface for wound healing; self-retaining.”

9. Similar codes to CPT 65778

Five similar codes to CPT 65778 and how they differentiate are:

  1. CPT 65779: Involves the placement of amniotic membrane on the ocular surface with sutures.
  2. CPT 65780: Refers to ocular surface reconstruction using a conjunctival limbal autograft.
  3. CPT 65781: Involves ocular surface reconstruction using a conjunctival limbal allograft.
  4. CPT 65782: Refers to ocular surface reconstruction using a keratolimbal allograft.
  5. CPT 65710: Involves a corneal transplant (penetrating keratoplasty).

10. Examples

  1. A patient with a persistent epithelial defect due to a corneal ulcer undergoes CPT 65778 to promote healing and prevent further complications.
  2. A patient with a chemical burn on the ocular surface receives CPT 65778 to facilitate tissue repair and minimize scarring.
  3. A patient with Stevens-Johnson syndrome undergoes CPT 65778 to promote healing of the ocular surface and improve visual function.
  4. A patient with ocular cicatricial pemphigoid receives CPT 65778 to reduce inflammation and promote tissue repair.
  5. A patient with a non-healing corneal abrasion undergoes CPT 65778 to facilitate wound healing and prevent infection.
  6. A patient with a corneal melt receives CPT 65778 to provide a protective barrier and promote tissue repair.
  7. A patient with a neurotrophic corneal ulcer undergoes CPT 65778 to stimulate healing and prevent further complications.
  8. A patient with a corneal perforation receives CPT 65778 to provide temporary support and promote healing until a more definitive treatment can be performed.
  9. A patient with a limbal stem cell deficiency undergoes CPT 65778 to provide a temporary protective barrier and promote healing of the ocular surface.
  10. A patient with a post-surgical ocular surface defect receives CPT 65778 to facilitate wound healing and improve visual outcomes.

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