How To Use CPT Code 65781

CPT code 65781 describes the procedure for ocular surface reconstruction using a limbal stem cell allograft. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 65781?

CPT 65781 can be used to describe the procedure for ocular surface reconstruction using a limbal stem cell allograft. This code is used when a provider utilizes limbal stem cells from either a living or cadaveric donor to reconstruct the surface of a patient’s eye that has been damaged by injury or disease.

2. Official Description

The official description of CPT code 65781 is: ‘Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor)’. This code specifically refers to the use of a limbal stem cell allograft for the reconstruction of the ocular surface.

3. Procedure

1. The provider prepares the graft from a living or cadaveric donor, removing the conjunctiva from the limbus and exposing the sclera.
2. The diseased or damaged corneal epithelium is excised.
3. The provider fits the limbal graft over the defect and sutures it into position.
4. Antibiotic ointment and steroid cream are applied to the eye, followed by the application of an eye patch and shield for protection.

4. Qualifying circumstances

Patients who may require CPT 65781 are those with damage or destruction of the limbus, resulting in abnormal corneal surface. The procedure involves the transplantation of limbal stem cells from a cadaver or living donor. The provider must ensure that the patient is appropriately prepped and anesthetized before performing the procedure.

5. When to use CPT code 65781

CPT code 65781 should be used when a provider performs ocular surface reconstruction using a limbal stem cell allograft. It is important to note that this code specifically refers to the use of a limbal stem cell allograft and should not be used for other types of ocular surface reconstruction procedures.

6. Documentation requirements

To support a claim for CPT 65781, the provider must document the following information:

• Patient’s diagnosis and the need for ocular surface reconstruction
• Details of the limbal stem cell allograft used, including whether it was obtained from a living or cadaveric donor
• Date of the procedure
• Specific steps performed during the procedure, such as removal of conjunctiva, excision of corneal epithelium, and suturing of the graft
• Application of antibiotic ointment, steroid cream, and eye patch
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 65781, ensure that the procedure involves the use of a limbal stem cell allograft and that the documentation supports the necessity of the procedure. It is important to follow the specific guidelines for reporting this code and to ensure that it is not reported with other codes that may overlap or duplicate the services provided.

8. Historical information

CPT 65781 was added to the Current Procedural Terminology system on January 1, 2004. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with severe corneal damage undergoes ocular surface reconstruction using a limbal stem cell allograft obtained from a cadaveric donor.
2. An individual who has suffered an eye injury receives ocular surface reconstruction with a limbal stem cell allograft from a living donor.
3. A patient with a chronic ocular surface disorder undergoes ocular surface reconstruction using a limbal stem cell allograft obtained from a cadaveric donor.
4. An individual with a corneal disease undergoes ocular surface reconstruction with a limbal stem cell allograft from a living donor.
5. A patient with a history of chemical burns to the eye receives ocular surface reconstruction using a limbal stem cell allograft obtained from a cadaveric donor.
6. An individual with a congenital ocular surface abnormality undergoes ocular surface reconstruction with a limbal stem cell allograft from a living donor.
7. A patient with corneal scarring undergoes ocular surface reconstruction using a limbal stem cell allograft obtained from a cadaveric donor.
8. An individual with a corneal infection receives ocular surface reconstruction with a limbal stem cell allograft from a living donor.
9. A patient with a corneal dystrophy undergoes ocular surface reconstruction using a limbal stem cell allograft obtained from a cadaveric donor.
10. An individual with a corneal ulcer undergoes ocular surface reconstruction with a limbal stem cell allograft from a living donor.