How To Use CPT Code 65815

CPT 65815 describes the procedure of paracentesis of the anterior chamber of the eye, which involves the removal of blood from the eye, with or without irrigation and/or air injection. 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 65815?

CPT 65815 is used to describe the specific procedure of paracentesis of the anterior chamber of the eye. This procedure involves the removal of blood from the front section of the eye, known as the anterior chamber. It may also include irrigation, which is the washing out of the area with water or medicated fluid, and/or air injection to ensure uniform intraocular pressure. Providers typically perform this procedure when the central retinal artery is blocked, as it can lead to permanent vision damage or blindness.

2. Official Description

The official description of CPT code 65815 is: ‘Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection.’ This code should not be used for injection procedures or the removal of blood clots, as there are separate codes for those specific procedures.

3. Procedure

1. Before the procedure, the patient is appropriately prepped and anesthetized.
2. The provider uses an eyelid speculum to hold the patient’s eye open.
3. A needle attached to a syringe is inserted into the anterior chamber of the eye to withdraw fluid and blood.
4. If a blood clot is present, the provider washes out the area with water or medicated fluid and aspirates the blood clot.
5. Air may be injected into the eye to ensure uniform intraocular pressure.

4. Qualifying circumstances

CPT 65815 is performed when the central retinal artery is blocked, leading to the accumulation of blood in the anterior chamber of the eye. This procedure is necessary to remove the blood and restore normal intraocular pressure. It should be performed by a qualified healthcare professional who is experienced in ophthalmic procedures.

5. When to use CPT code 65815

CPT code 65815 should be used when performing a separate procedure to remove blood from the anterior chamber of the eye. It should not be reported if it is integral to the performance of a larger procedure at the same time. Providers should carefully evaluate the necessity of this procedure and ensure that it is performed only when medically necessary.

6. Documentation requirements

To support a claim for CPT code 65815, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Date and time of the procedure
• Details of the procedure, including the removal of blood, irrigation, and/or air injection
• Any complications or additional interventions performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 65815, ensure that the procedure is performed as a separate procedure and not integral to a larger procedure. It is important to follow the specific guidelines and documentation requirements for accurate billing. Providers should also be aware of any specific payer policies or requirements for reporting this code.

8. Historical information

CPT code 65815 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 provider performs paracentesis of the anterior chamber of the eye to remove blood and irrigate the area for a patient with a blocked central retinal artery.
2. During a separate procedure, a provider performs paracentesis of the anterior chamber of the eye to remove blood and inject air to ensure uniform intraocular pressure for a patient with vision complications.
3. A qualified healthcare professional performs paracentesis of the anterior chamber of the eye to remove blood and irrigate the area with medicated fluid for a patient with an eye injury.
4. For a patient with a blood clot in the anterior chamber of the eye, a provider performs paracentesis to remove the clot and inject air to restore normal intraocular pressure.
5. During a separate procedure, a provider performs paracentesis of the anterior chamber of the eye to remove blood and introduce a therapeutic solution for a patient with a specific eye condition.