How To Use CPT Code 67440

CPT 67440 describes a specific procedure known as orbitotomy with bone flap or window, lateral approach. This article will provide an overview of the code, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of when CPT 67440 may be used.

1. What is CPT Code 67440?

CPT 67440 is a code that represents a surgical procedure called orbitotomy with bone flap or window, lateral approach. This procedure involves making an incision through the side of the orbit, which is the bony cavity that holds the eyes. The purpose of this procedure is to access and drain fluid accumulations, such as cysts or abscesses, by temporarily removing a segment of bone known as a bone flap or leaving a bone window open after the procedure.

2. Official Description

The official description of CPT code 67440 is: ‘Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage.’

3. Procedure

1. During the procedure, the healthcare provider begins by making a small incision over the lateral canthus, which is the outer corner of the eyes where the eyelids come together.
2. The provider then exposes the superior maxilla, inferior frontal bone, zygoma, and zygomatic arch by extending the incision and removing the bone with a high-speed burr.
3. Once the deep lateral wall is reached, the provider continues the incision up to the supraorbital rim, exposing the orbital apex.
4. The fluid collection is identified and drained, taking care to avoid any harm to nearby structures.
5. The bone flap is then returned to its original position, and the provider repairs the orbital roof or leaves a bone window, attaching a suction device if necessary.
6. The area is irrigated, checked for bleeding, and the incision is closed in layers.

4. Qualifying circumstances

CPT 67440 is performed when there is a need to drain fluid accumulations, such as abscesses or cysts, in the orbit. The procedure is typically done when other approaches, with or without exploration, are not suitable. It is important to note that the procedure requires the expertise of a healthcare provider who is trained in performing orbitotomy with a lateral approach.

5. When to use CPT code 67440

CPT code 67440 should be used when a healthcare provider performs orbitotomy with bone flap or window, lateral approach, for the purpose of draining fluid accumulations in the orbit. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

When documenting a claim for CPT code 67440, the healthcare provider must include the following information:

• Patient’s diagnosis necessitating the procedure
• Details of the procedure performed, including the specific approach used
• Date of the procedure
• Any additional procedures or services provided during the same encounter
• Any complications or unexpected findings
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 67440, it is important to ensure that the procedure meets the specific criteria outlined in the code description. Additionally, it is crucial to follow any applicable payer guidelines and modifiers. It is also important to note that CPT code 67440 should not be reported with other codes in the range of 67400-67450, which cover exploration, excision, and decompression on the orbit of the ocular adnexa.

8. Historical information

CPT code 67440 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 healthcare provider performs orbitotomy with bone flap or window, lateral approach, to drain an abscess in the orbit.
2. During a surgical procedure, a bone window is left open after orbitotomy with a lateral approach to allow for drainage of a cyst in the orbit.
3. A patient undergoes orbitotomy with bone flap or window, lateral approach, to remove a fluid accumulation in the orbit caused by an infection.
4. A healthcare provider performs orbitotomy with bone flap or window, lateral approach, to drain an abscess in the orbit caused by trauma.
5. During a surgical procedure, a bone flap is temporarily removed to access and drain a cyst in the orbit.
6. A patient undergoes orbitotomy with bone flap or window, lateral approach, to remove a fluid accumulation in the orbit caused by a tumor.
7. A healthcare provider performs orbitotomy with bone flap or window, lateral approach, to drain an abscess in the orbit caused by an inflammatory condition.
8. During a surgical procedure, a bone window is left open after orbitotomy with a lateral approach to allow for drainage of a cyst in the orbit caused by a congenital anomaly.
9. A patient undergoes orbitotomy with bone flap or window, lateral approach, to remove a fluid accumulation in the orbit caused by a vascular malformation.
10. A healthcare provider performs orbitotomy with bone flap or window, lateral approach, to drain an abscess in the orbit caused by an autoimmune disease.