How To Use CPT Code 65865

CPT 65865 describes the incisional technique used to sever adhesions or goniosynechiae in the anterior segment of the eye, specifically for the treatment of glaucoma. 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 65865?

CPT 65865 is a code used to describe the incisional technique performed by a healthcare provider to sever adhesions or goniosynechiae in the anterior segment of the eye. This procedure is specifically used for the treatment of glaucoma. It involves making a full-thickness incision in the cornea, creating flaps to access the anterior chamber of the eye, and then splitting the goniosynechiae through the incision. The provider may also inject air or liquid to stabilize the pressure of the eye at the end of the procedure.

2. Official Description

The official description of CPT code 65865 is: ‘Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae.’

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The healthcare provider places a lid speculum to provide exposure and allow for paracentesis.
3. An anesthetic is instilled, and the provider uses a blade to make a full-thickness incision in the cornea, creating flaps to access the anterior chamber.
4. The provider then splits the goniosynechiae through the incision.
5. Air or liquid may be injected to stabilize the pressure of the eye at the end of the procedure.

4. Qualifying circumstances

CPT 65865 is used for patients with glaucoma who have adhesions or goniosynechiae in the anterior segment of the eye. Adhesions are fibrous bands that form between tissues and organs, while goniosynechiae are adhesions of the iris to the posterior surface of the cornea in the angle of the anterior chamber of the eye. This procedure is performed by a healthcare provider to treat these conditions and improve the patient’s eye health.

5. When to use CPT code 65865

CPT code 65865 should be used when a healthcare provider performs the incisional technique to sever adhesions or goniosynechiae in the anterior segment of the eye for the treatment of glaucoma. It is important to note that this code should not be reported when performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach. If the procedure is performed with an unrelated procedure, modifier 59, Distinct procedural service, should be appended to the code.

6. Documentation requirements

To support a claim for CPT code 65865, the healthcare provider must document the following information:

• Patient’s diagnosis of glaucoma and the presence of adhesions or goniosynechiae
• Details of the procedure performed, including the incisional technique used and any injection of air or liquid
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 65865, ensure that the procedure is performed to sever adhesions or goniosynechiae in the anterior segment of the eye for the treatment of glaucoma. This code should not be reported when performed with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach. If the procedure is performed with an unrelated procedure, modifier 59 should be appended to the code. It is important to review the documentation and ensure that it supports the use of the modifier.

8. Historical information

CPT code 65865 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs an incisional technique to sever adhesions in the anterior segment of the eye for a patient with glaucoma.
2. A patient with glaucoma undergoes a procedure to split goniosynechiae in the anterior chamber of the eye.
3. A healthcare provider uses an incisional technique to treat adhesions in the anterior segment of the eye for a patient with glaucoma.
4. A procedure is performed to sever goniosynechiae in the anterior chamber of the eye for a patient diagnosed with glaucoma.
5. A patient with glaucoma undergoes an incisional technique to treat adhesions in the anterior segment of the eye.
6. A healthcare provider performs a procedure to split goniosynechiae in the anterior chamber of the eye for a patient with glaucoma.
7. An incisional technique is used to treat adhesions in the anterior segment of the eye for a patient diagnosed with glaucoma.
8. A patient with glaucoma undergoes a procedure to sever goniosynechiae in the anterior chamber of the eye.
9. A healthcare provider performs an incisional technique to treat adhesions in the anterior segment of the eye for a patient with glaucoma.
10. A procedure is performed to split goniosynechiae in the anterior chamber of the eye for a patient diagnosed with glaucoma.