How To Use CPT Code 0402T

CPT 0402T describes a procedure performed on the cornea that involves collagen cross-linking, removal of the corneal epithelium, and intraoperative pachymetry. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of CPT code 0402T.

1. What is CPT Code 0402T?

CPT 0402T is a code used to describe a specific procedure performed on the cornea. This procedure involves collagen cross-linking, which strengthens the corneal fibers and makes the cornea stiffer and stronger. Additionally, the procedure may include the removal of the corneal epithelium, the thin layer that covers the surface of the eye, and intraoperative pachymetry, which measures the thickness of the cornea. It is important to note that medication used during the procedure should be reported separately, and CPT code 0402T should not be reported in conjunction with codes 65435, 69990, or 76514.

2. Official Description

The official description of CPT code 0402T is: ‘Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed (Report medication separately) (Do not report 0402T in conjunction with 65435, 69990, 76514)’

3. Procedure

1. The provider begins the procedure by assessing the patient’s condition and determining the need for collagen cross-linking of the cornea.
2. If necessary, the provider may choose to remove the corneal epithelium to improve the absorption of the medication used during the procedure.
3. The provider then applies riboflavin (vitamin B2) drops onto the cornea, saturating it with the solution.
4. Once the cornea is saturated, the provider exposes the eye to ultraviolet rays, which activates the riboflavin and strengthens the natural attachments between the corneal structures.
5. Intraoperative pachymetry may be performed to measure the thickness of the cornea during the procedure.
6. Throughout the procedure, the provider may use numbing anesthetic drops and mild sedation to ensure the patient’s comfort.

4. Qualifying circumstances

CPT code 0402T is typically performed for patients with keratoconus, a degenerative eye disease that causes a change in the shape of the cornea. The procedure is intended to strengthen the corneal fibers and provide structural support. It is important to note that the procedure should only be performed by a qualified provider and when medically necessary.

5. When to use CPT code 0402T

CPT code 0402T should be used when the provider performs collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry. It is important to report this code separately for each procedure performed. However, it should not be reported in conjunction with codes 65435, 69990, or 76514.

6. Documentation requirements

In order to support a claim for CPT code 0402T, the provider must document the following information:

• Patient’s diagnosis and the medical necessity of the procedure
• Details of the procedure performed, including collagen cross-linking, removal of the corneal epithelium, and intraoperative pachymetry
• Date and duration of the procedure
• Any medications used during the procedure, which should be reported separately
• Results of the intraoperative pachymetry, if performed
• Any additional relevant information or findings

7. Billing guidelines

When billing for CPT code 0402T, it is important to ensure that the procedure meets the criteria outlined in the code description. The provider should report the code separately for each procedure performed. It is also important to note that CPT code 0402T should not be reported in conjunction with codes 65435, 69990, or 76514. Additionally, any medications used during the procedure should be reported separately.

8. Historical information

CPT code 0402T was added to the Current Procedural Terminology system on January 1, 2016. Since its addition, there have been a few changes to the code description, including the inclusion of the removal of the corneal epithelium and intraoperative pachymetry in the official description.

9. Examples

1. A patient with keratoconus undergoes collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry to strengthen the corneal fibers and improve the structural support of the cornea.
2. A provider performs collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry for a patient with a degenerative eye disease, such as keratoconus, to prevent further deterioration of the cornea.
3. During a procedure, a provider applies riboflavin drops to the cornea, removes the corneal epithelium, and performs intraoperative pachymetry to enhance the strength and thickness of the cornea in a patient with a corneal disorder.
4. A patient with keratoconus undergoes collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry to stabilize the cornea and improve visual acuity.
5. A provider performs collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry to treat a patient with a corneal condition that requires strengthening of the corneal fibers.
6. During a procedure, a provider applies riboflavin drops to the cornea, removes the corneal epithelium, and performs intraoperative pachymetry to improve the structural integrity and thickness of the cornea in a patient with a corneal disorder.
7. A patient with keratoconus undergoes collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry to halt the progression of the corneal disease and maintain visual function.
8. A provider performs collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry to strengthen the corneal fibers and improve the stability of the cornea in a patient with a corneal disorder.
9. During a procedure, a provider applies riboflavin drops to the cornea, removes the corneal epithelium, and performs intraoperative pachymetry to enhance the strength and thickness of the cornea in a patient with a corneal condition.
10. A patient with keratoconus undergoes collagen cross-linking of the cornea, including the removal of the corneal epithelium, and intraoperative pachymetry to stabilize the cornea and improve visual acuity.