How To Use CPT Code 67415

CPT 67415 describes the fine needle aspiration of orbital contents, a procedure used to extract material from suspicious tissue within the orbit. 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 67415?

CPT 67415 can be used to describe the fine needle aspiration of orbital contents. This procedure involves the extraction of material from an area of suspicious tissue within the orbit, which is the bony cavity that holds the eyes. The provider uses a narrow needle to extract a sample of tissue, which is then sent to a laboratory for analysis to determine the nature of the suspicious tissue.

2. Official Description

The official description of CPT code 67415 is: ‘Fine needle aspiration of orbital contents.’

3. Procedure

1. The provider prepares and anesthetizes the patient appropriately.
2. With the aid of fluoroscopy or other imaging guidance, the provider inserts a thin hollow needle through the orbit into an area that contains suspicious tissue.
3. The provider withdraws a sample of tissue through the needle.
4. The sample is then submitted to a laboratory for analysis.
5. The provider inspects the area for bleeding and dresses the wound.

4. Qualifying circumstances

CPT 67415 is performed when there is a need to extract material from suspicious tissue within the orbit. This procedure is typically done when there is a suspicion of a tumor or other abnormal growth in the orbital contents. It is important to note that CPT 67415 should not be reported for exenteration, enucleation, repair, or optic nerve decompression procedures.

5. When to use CPT code 67415

CPT code 67415 should be used when the provider performs a fine needle aspiration of orbital contents. It is important to ensure that the procedure is performed for the purpose of extracting material from suspicious tissue within the orbit. This code should not be used for other procedures such as exenteration, enucleation, repair, or optic nerve decompression.

6. Documentation requirements

To support a claim for CPT 67415, the provider must document the following information:

• Reason for performing the fine needle aspiration
• Details of the procedure, including the use of fluoroscopy or other imaging guidance
• Description of the suspicious tissue and the location within the orbit
• Sample of tissue extracted and sent for analysis
• Inspection of the area for bleeding and dressing of the wound

7. Billing guidelines

When billing for CPT 67415, ensure that the procedure performed is a fine needle aspiration of orbital contents. It is important to report any additional procedures separately, such as microsurgical techniques or fluoroscopy or other imaging guidance. It is also important to note that CPT 67415 should not be reported with codes for exenteration, enucleation, repair, or optic nerve decompression.

8. Historical information

CPT 67415 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 provider performs a fine needle aspiration of orbital contents to extract a sample of suspicious tissue for analysis.
2. Using fluoroscopy guidance, a provider performs a fine needle aspiration to obtain a sample from a suspected tumor within the orbit.
3. A patient presents with an abnormal growth in the orbital contents, and the provider performs a fine needle aspiration to determine the nature of the growth.
4. During a procedure, the provider performs a fine needle aspiration to extract material from suspicious tissue within the orbit.
5. A provider performs a fine needle aspiration on a patient with a suspected orbital tumor to obtain a sample for analysis.
6. Using microsurgical techniques, a provider performs a fine needle aspiration to extract material from suspicious tissue within the orbit.
7. A patient undergoes a fine needle aspiration of orbital contents to obtain a sample for further analysis.
8. During a surgical procedure, the provider performs a fine needle aspiration to extract material from suspicious tissue within the orbit.
9. A provider performs a fine needle aspiration on a patient with a suspected orbital tumor to determine the nature of the growth.
10. Using imaging guidance, a provider performs a fine needle aspiration to obtain a sample from suspicious tissue within the orbit.