How To Use CPT Code 65855

CPT 65855 is a code used for trabeculoplasty by laser surgery, a procedure to treat glaucoma by opening up blockages in the trabecular meshwork. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 65855 procedures.

1. What is CPT 65855?

CPT 65855 is a code used to describe trabeculoplasty by laser surgery, a procedure performed to treat glaucoma by opening up blockages in the trabecular meshwork, the tissue of mesh where the iris meets the sclera. This allows the aqueous humor to drain from the anterior chamber, reducing intraocular pressure and alleviating glaucoma symptoms.

2. 65855 CPT code description

The official description of CPT code 65855 is: “Trabeculoplasty by laser surgery.”

3. Procedure

The 65855 procedure involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. Eye drops are applied to narrow the pupil.
3. A customized contact lens is placed on the eye to enable the provider to see the trabecular meshwork.
4. A laser light is used to burn the trabecular meshwork along the iris, opening up blockages of aqueous humor.
5. The aqueous fluid from the eyes flows out rapidly, reducing intraocular pressure.
6. One or more sessions may be needed to complete the treatment.

4. Qualifying circumstances

Patients eligible to receive CPT code 65855 services are those diagnosed with glaucoma who have not responded well to other treatments, such as medication or conventional surgery. The procedure is typically recommended for patients with open-angle glaucoma, where the drainage angle between the iris and cornea remains open, but the trabecular meshwork is partially blocked.

5. When to use CPT code 65855

It is appropriate to bill the 65855 CPT code when the provider performs any laser trabeculoplasty procedure, whether it’s argon laser trabeculoplasty (ALT), diode laser trabeculoplasty (DLT), or selective laser trabeculoplasty (SLT). The code should not be reported in conjunction with 65860, 65865, 65870, 65875, 65880, or 0730T. For trabeculectomy, use CPT 66170, and for trabeculotomy by laser, including optical coherence tomography (OCT) image guidance, use CPT 0730T.

6. Documentation requirements

To support a claim for CPT 65855, the following information should be documented:

• Patient’s medical history and diagnosis of glaucoma.
• Previous treatments attempted and their outcomes.
• Indication that the patient is an appropriate candidate for laser trabeculoplasty.
• Details of the procedure, including the type of laser used, the number of sessions, and the specific trabecular meshwork areas treated.
• Postoperative care instructions and follow-up appointments.

7. Billing guidelines

When billing for CPT code 65855, it is essential to follow the appropriate guidelines and rules. Ensure that the patient’s medical record contains all necessary documentation to support the claim, as outlined in the documentation requirements section. Additionally, be aware of any payer-specific guidelines or requirements that may apply to the billing of this code.

8. Historical information

CPT 65855 was added to the Current Procedural Terminology system in 1990. The code has undergone changes in its descriptor over the years, with the most recent change occurring in 2016.

9. Similar codes to CPT 65855

Five similar codes to CPT 65855 and how they differentiate are:

1. CPT 66170: This code is used for trabeculectomy, a different surgical procedure to treat glaucoma by creating a new drainage pathway for the aqueous humor.
2. CPT 0730T: This code is used for trabeculotomy by laser, including optical coherence tomography (OCT) image guidance, another laser-based procedure to treat glaucoma.
3. CPT 65860: This code is used for goniotomy, a surgical procedure to open the trabecular meshwork by cutting it with a specialized instrument.
4. CPT 65865: This code is used for goniosynechialysis, a procedure to separate the iris from the trabecular meshwork to improve aqueous humor drainage.
5. CPT 65870: This code is used for goniotomy with trabeculotomy, a combination of the two procedures to treat glaucoma.

10. Examples

Here are 10 detailed examples of CPT code 65855 procedures:

1. A 60-year-old patient with open-angle glaucoma undergoes argon laser trabeculoplasty (ALT) to improve aqueous humor drainage and reduce intraocular pressure.
2. A 45-year-old patient with a history of uncontrolled glaucoma undergoes diode laser trabeculoplasty (DLT) after unsuccessful medical management.
3. A 55-year-old patient with open-angle glaucoma undergoes selective laser trabeculoplasty (SLT) as a primary treatment option.
4. A 65-year-old patient with open-angle glaucoma undergoes ALT as an adjunctive treatment to medication therapy.
5. A 50-year-old patient with pigmentary glaucoma undergoes SLT to improve aqueous humor drainage and reduce intraocular pressure.
6. A 70-year-old patient with open-angle glaucoma undergoes DLT after unsuccessful conventional surgery.
7. A 62-year-old patient with open-angle glaucoma undergoes ALT as a secondary treatment option after unsuccessful trabeculectomy.
8. A 58-year-old patient with open-angle glaucoma undergoes SLT as a primary treatment option due to intolerance to glaucoma medications.
9. A 67-year-old patient with open-angle glaucoma undergoes DLT as an adjunctive treatment to medication therapy.
10. A 53-year-old patient with open-angle glaucoma undergoes ALT after unsuccessful goniotomy.