How To Use CPT Code 68040

CPT 68040 describes the procedure for removing conjunctival follicles to relieve pain and irritation. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 68040?

CPT 68040 is used to describe the procedure of removing conjunctival follicles to alleviate discomfort and irritation. This code is utilized when a healthcare provider eliminates these follicles, which are small cavities or glands that secrete fluid, to provide relief to the patient.

2. Official Description

The official description of CPT code 68040 is: ‘Expression of conjunctival follicles (eg, for trachoma).’ This procedure involves the removal of conjunctival follicles to alleviate pain and irritation. Please note that if the provider performs an automated evacuation of the Meibomian glands, CPT code 0207T should be used instead.

3. Procedure

1. During this procedure, the healthcare provider prepares and anesthetizes the patient.
2. The provider reverts the eyelid to access the conjunctiva.
3. With the assistance of a biomicroscope and slit lamp, the provider visualizes the conjunctiva.
4. Using a curette or cotton swab, the provider carefully removes the conjunctival follicles.
5. The procedure is performed until all follicles causing discomfort and irritation are removed.

4. Qualifying circumstances

This procedure is performed on patients who experience pain and irritation due to conjunctival follicles. It is commonly used for conditions such as trachoma, an infection affecting the conjunctiva and cornea. The patient must be appropriately prepped and anesthetized before the procedure. The healthcare provider must have the necessary skills and expertise to perform the procedure safely and effectively.

5. When to use CPT code 68040

CPT code 68040 should be used when a healthcare provider performs the procedure to remove conjunctival follicles. It is important to ensure that the patient is experiencing pain and irritation due to these follicles and that the procedure is necessary for their relief. This code should not be used for other procedures or conditions unrelated to the removal of conjunctival follicles.

6. Documentation requirements

To support a claim for CPT code 68040, the healthcare provider must document the following information:

• Patient’s symptoms and the need for the procedure
• Details of the procedure, including the use of a curette or cotton swab
• Date and duration of the procedure
• Any complications or additional treatments provided
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 68040, ensure that the procedure is performed by a qualified healthcare provider and is necessary for the patient’s relief. It is important to follow the specific guidelines and requirements set by the payer. Additionally, if an automated evacuation of the Meibomian glands is performed instead, CPT code 0207T should be used. Take into consideration any modifiers or additional codes that may be required for accurate billing.

8. Historical information

CPT code 68040 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 performing the procedure to remove conjunctival follicles for a patient experiencing pain and irritation due to trachoma.
2. A patient with conjunctival follicles seeks relief from discomfort and undergoes the procedure performed by a healthcare provider.
3. A healthcare provider removes conjunctival follicles to alleviate pain and irritation caused by an infection affecting the conjunctiva and cornea.
4. A patient presents with conjunctival follicles, and a healthcare provider performs the procedure to provide relief from discomfort and irritation.
5. A healthcare provider performs the procedure to remove conjunctival follicles for a patient who has been experiencing pain and irritation for an extended period.
6. A patient with conjunctival follicles undergoes the procedure to alleviate discomfort and irritation under the care of a healthcare provider.
7. A healthcare provider performs the procedure to remove conjunctival follicles for a patient who has failed to find relief from other treatments.
8. A patient seeks relief from pain and irritation caused by conjunctival follicles and undergoes the procedure performed by a healthcare provider.
9. A healthcare provider performs the procedure to remove conjunctival follicles for a patient who has been experiencing persistent discomfort and irritation.
10. A patient with conjunctival follicles undergoes the procedure to alleviate pain and irritation under the care of a healthcare provider.