How To Use CPT Code 65410

CPT 65410 describes the procedure for biopsy of the cornea, which involves the removal of suspicious tissues for further analysis. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 65410?

CPT 65410 is used to describe the biopsy procedure performed on the cornea. This involves the removal of a portion or the entirety of suspicious tissue on the cornea for further examination. The provider uses a sterile trephine, a specialized instrument, to remove a circular piece of tissue, including both the suspicious tissue and some healthy tissue. The specimen is then sent to a laboratory for analysis.

2. Official Description

The official description of CPT code 65410 is: ‘Biopsy of cornea. The provider takes samples of suspicious tissues on the cornea to determine the presence of corneal disease. He submits the specimen to a laboratory for analysis.’

3. Procedure

1. When performing a corneal biopsy, the patient is appropriately prepped and anesthetized.
2. The provider uses a sterile trephine, which is an instrument that removes a circular piece of tissue, to obtain a sample of the suspicious tissue on the cornea.
3. In addition to the suspicious tissue, the provider also includes some healthy tissue in the biopsy specimen.
4. The collected specimen is then sent to a laboratory for further analysis to determine the presence of any corneal disease.

4. Qualifying circumstances

CPT 65410 is performed when there are suspicious tissues on the cornea that require further examination to determine the presence of corneal disease. The procedure is typically performed by a qualified healthcare provider who is trained in corneal biopsies. It is important to note that the patient must be appropriately prepped and anesthetized before the procedure.

5. When to use CPT code 65410

CPT code 65410 should be used when a corneal biopsy is performed to obtain samples of suspicious tissues on the cornea for analysis. It is important to ensure that the procedure is necessary and meets the criteria for corneal biopsy. This code should not be used for other types of biopsies or procedures performed on different parts of the eye.

6. Documentation requirements

To support a claim for CPT 65410, the healthcare provider must document the following information:

• Patient’s medical history and the reason for performing the corneal biopsy
• Details of the procedure, including the use of a sterile trephine and the removal of suspicious tissue
• Description of the collected specimen and its submission to a laboratory for analysis
• Any complications or adverse events that occurred during or after the procedure
• Signature of the healthcare provider performing the corneal biopsy

7. Billing guidelines

When billing for CPT 65410, ensure that the procedure meets the criteria for corneal biopsy and that the documentation supports the necessity of the procedure. It is important to use the appropriate CPT code for the specific procedure performed and not to report CPT 65410 for other types of biopsies or procedures on different parts of the eye.

8. Historical information

CPT 65410 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient presents with a suspicious corneal lesion, and the provider performs a biopsy using a sterile trephine to obtain a tissue sample for analysis.
2. During a routine eye examination, the provider identifies suspicious tissues on the cornea and decides to perform a corneal biopsy to determine the presence of corneal disease.
3. A patient with a history of corneal disease experiences worsening symptoms, leading the provider to perform a corneal biopsy to assess the progression of the condition.
4. Following a corneal injury, the provider performs a biopsy to evaluate the extent of the damage and determine the appropriate treatment plan.
5. A patient with a family history of corneal disease undergoes a corneal biopsy as a precautionary measure to detect any early signs of the condition.
6. During a corneal transplant surgery, the provider performs a biopsy on the donor cornea to ensure its suitability for transplantation.
7. A patient with recurring corneal infections undergoes a corneal biopsy to identify the underlying cause and guide the treatment approach.
8. As part of a research study on corneal diseases, the provider performs corneal biopsies on a group of participants to collect tissue samples for analysis.
9. A patient with a suspected corneal tumor undergoes a corneal biopsy to determine the nature of the growth and plan the appropriate treatment.
10. Following a corneal transplant rejection, the provider performs a biopsy to assess the immune response and guide the management of the patient’s condition.