How To Use CPT Code 65800

CPT 65800 describes the procedure of paracentesis of the anterior chamber of the eye, which involves the removal of aqueous fluid. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 65800?

CPT 65800 can be used to describe the procedure of paracentesis of the anterior chamber of the eye, specifically involving the removal of aqueous fluid. This code is used when a healthcare provider drains fluid from the front section of the eye, known as the anterior chamber, and removes the thin, watery fluid called aqueous.

2. Official Description

The official description of CPT code 65800 is: ‘Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous.’

3. Procedure

1. During the procedure, the healthcare provider prepares the patient and administers anesthesia.
2. Using an eyelid speculum to keep the eye open, the provider inserts a needle attached to a syringe into the anterior chamber of the eye.
3. The provider then aspirates the aqueous fluid, reducing the intraocular pressure inside the eye.
4. If necessary, the provider may also block the central retinal artery.
5. The aspirated sample is sent to the laboratory for examination.

4. Qualifying circumstances

CPT 65800 is typically performed when the central retinal artery is blocked, which can lead to vision damage or blindness. The procedure is done to drain fluid from the anterior chamber of the eye and remove the aqueous fluid. It is important to note that this code should only be reported when it is not an integral part of a larger procedure performed at the same time.

5. When to use CPT code 65800

CPT code 65800 should be used when a healthcare provider performs the separate procedure of paracentesis of the anterior chamber of the eye with the specific purpose of removing aqueous fluid. It should not be reported if it is part of a larger procedure performed simultaneously.

6. Documentation requirements

To support a claim for CPT 65800, the healthcare provider must document the following information:

• Reason for performing the procedure, such as a blocked central retinal artery
• Details of the procedure, including the use of an eyelid speculum and the insertion of a needle into the anterior chamber
• Documentation of the removal of aqueous fluid
• Any additional procedures performed during the same session
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 65800, ensure that the procedure is performed as a separate procedure and not as part of a larger procedure. It is important to follow the specific guidelines for reporting this code accurately. Additionally, consider any relevant tips for reporting CPT 65800, such as not reporting it if it is integral to a larger procedure.

8. Historical information

CPT 65800 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2013, where the description was updated to include the removal of aqueous fluid.

9. Examples

1. A healthcare provider performs paracentesis of the anterior chamber of the eye to remove aqueous fluid from a patient with a blocked central retinal artery.
2. During the procedure, the provider drains fluid from the anterior chamber and removes aqueous fluid to reduce intraocular pressure in a patient with glaucoma.
3. A patient undergoes paracentesis of the anterior chamber of the eye to remove aqueous fluid as part of a separate procedure to diagnose a specific eye condition.
4. A healthcare provider performs paracentesis of the anterior chamber of the eye to remove aqueous fluid and relieve pressure in a patient with ocular hypertension.
5. During the procedure, the provider drains fluid from the anterior chamber and removes aqueous fluid to treat a patient with corneal edema.
6. A patient undergoes paracentesis of the anterior chamber of the eye to remove aqueous fluid as part of a separate procedure to investigate the cause of recurrent eye infections.
7. A healthcare provider performs paracentesis of the anterior chamber of the eye to remove aqueous fluid and alleviate symptoms in a patient with uveitis.
8. During the procedure, the provider drains fluid from the anterior chamber and removes aqueous fluid to relieve pain and pressure in a patient with acute angle-closure glaucoma.
9. A patient undergoes paracentesis of the anterior chamber of the eye to remove aqueous fluid as part of a separate procedure to investigate the cause of persistent eye redness.
10. A healthcare provider performs paracentesis of the anterior chamber of the eye to remove aqueous fluid and improve vision in a patient with Fuchs’ dystrophy.