How To Use CPT Code 67316

CPT 67316 describes a specific surgical procedure used to correct strabismus, a condition in which the eyes are misaligned and point in different directions. 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 67316?

CPT 67316 is a code used to describe a surgical procedure performed to realign the eye muscles in order to correct strabismus. The physician may either perform a recession (weakening) or resection (strengthening) of two or more vertical muscles, excluding the superior oblique muscle. This procedure aims to improve the patient’s vision and alignment of the eyes.

2. Official Description

The official description of CPT code 67316 is: ‘Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique).’ It is important to note that for adjustable sutures, an additional code, 67335, should be used in conjunction with codes 67311-67334 to reflect the number of muscles operated on.

3. Procedure

1. The surgeon administers anesthesia to the patient.
2. An incision is made either into the fornix or in the limbal area of the eye.
3. A recession of the medial rectus muscle is performed.
4. The muscle surrounding the Tenon’s capsule is dissected.
5. Subconjunctival areolar tissue is cut using scissors and forceps to expose the muscle.
6. A blunt hook or forceps is used to elevate the targeted muscle for traction.
7. Sutures are placed into the muscles and clamped before removing them.

4. Qualifying circumstances

CPT 67316 is used for patients with strabismus, a condition in which the eyes are misaligned. The procedure involves the recession or resection of two or more vertical muscles, excluding the superior oblique muscle. It is important to note that the inferior oblique muscle is considered a vertical muscle, while the superior oblique muscle is not. Therefore, repairs of the superior oblique muscle should be reported with CPT code 67318.

5. When to use CPT code 67316

CPT code 67316 should be used when a surgeon performs a recession or resection procedure on two or more vertical muscles, excluding the superior oblique muscle, to correct strabismus. It is important to accurately document the specific muscles operated on and the nature of the procedure.

6. Documentation requirements

To support a claim for CPT 67316, the surgeon must document the following information:

• Patient’s diagnosis of strabismus
• Specific muscles operated on (excluding the superior oblique muscle)
• Details of the recession or resection procedure
• Date of the surgery
• Any additional procedures performed in conjunction with CPT 67316
• Signature of the surgeon

7. Billing guidelines

When billing for CPT 67316, ensure that the surgeon performs a recession or resection procedure on two or more vertical muscles, excluding the superior oblique muscle. It is important to follow the guidelines provided by the payer and accurately document the procedure to support the claim. Additionally, consider any additional procedures performed in conjunction with CPT 67316 and report them accordingly.

8. Historical information

CPT 67316 was added to the Current Procedural Terminology system on January 1, 1991. The code underwent a change on January 1, 2009, with an updated description: ‘Strabismus surgery, recession or resection procedure; two or more vertical muscles (excluding superior oblique).’ No further updates have been made to the code since then.

9. Examples

1. A surgeon performs a recession procedure on the medial rectus and inferior rectus muscles to correct strabismus in a patient.
2. During a strabismus surgery, a surgeon performs a resection procedure on the superior rectus and inferior rectus muscles.
3. A patient with esotropia undergoes a recession procedure on the medial rectus and inferior rectus muscles to realign their eyes.
4. A surgeon performs a resection procedure on the medial rectus and inferior oblique muscles to correct exotropia in a patient.
5. During a strabismus surgery, a surgeon performs a recession procedure on the superior rectus and inferior oblique muscles to improve eye alignment.
6. A patient with strabismus undergoes a resection procedure on the medial rectus and inferior oblique muscles to correct their eye misalignment.
7. A surgeon performs a recession procedure on the superior rectus and inferior oblique muscles to correct strabismus in a patient.
8. During a strabismus surgery, a surgeon performs a resection procedure on the medial rectus and inferior rectus muscles.
9. A patient with esotropia undergoes a recession procedure on the medial rectus and inferior rectus muscles to realign their eyes.
10. A surgeon performs a resection procedure on the medial rectus and inferior oblique muscles to correct exotropia in a patient.