How To Use CPT Code 68115

CPT 68115 describes the excision of a lesion on the conjunctiva that is larger than 1 cm in size. 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 68115?

CPT 68115 is used to describe the excision of a lesion on the conjunctiva that is larger than 1 cm in size. This procedure is performed to alleviate pain, pressure, and improve vision for the patient.

2. Official Description

The official description of CPT code 68115 is: ‘Excision of lesion, conjunctiva; over 1 cm.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. A lid speculum is placed to keep the eye open, and the provider examines the eye.
3. A traction suture is placed to the nasal limbus to provide stability.
4. A corneal light shield is used to protect the eye from phototoxicity.
5. The provider marks the conjunctival lesion using a fine tip marker, leaving a margin of approximately 3 to 4 mm.
6. The lesion, measuring over 1 cm, is excised by the provider.
7. If necessary, the incision is sutured by the provider.

4. Qualifying circumstances

CPT 68115 is performed when there is a lesion on the conjunctiva that is larger than 1 cm in size. The excision of the lesion is necessary to alleviate pain, pressure, and improve vision for the patient.

5. When to use CPT code 68115

CPT code 68115 should be used when the provider performs the excision of a lesion on the conjunctiva that is larger than 1 cm in size. It is important to review the operative note to ensure that the provider performed a full excision of the lesion and not just a biopsy.

6. Documentation requirements

To support a claim for CPT 68115, the provider must document the following information:

• Patient’s diagnosis and the need for excision of the conjunctival lesion
• Size of the lesion, confirming it is larger than 1 cm
• Details of the procedure, including prepping, anesthesia administration, and the use of lid speculum, traction suture, and corneal light shield
• Margin left around the lesion during marking
• Confirmation of the excision of the lesion
• If applicable, documentation of suturing the incision

7. Billing guidelines

When billing for CPT 68115, ensure that the provider performed the excision of a conjunctival lesion larger than 1 cm. It is important to review the operative note to determine if the provider performed an actual full excision or just a biopsy. If a biopsy was performed, a different code should be used. It is also important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 68115 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 patient presents with a conjunctival lesion measuring 1.5 cm in size. The provider performs the excision of the lesion to alleviate the patient’s discomfort and improve vision.
2. During an eye examination, a provider discovers a conjunctival lesion measuring 2 cm in size. The patient experiences pain and pressure due to the lesion, and the provider decides to perform an excision to provide relief.
3. A patient with a conjunctival lesion measuring 1.2 cm in size seeks medical attention. The provider determines that the excision of the lesion is necessary to alleviate the patient’s symptoms and improve their vision.
4. After a thorough examination, a provider diagnoses a patient with a conjunctival lesion measuring 1.8 cm in size. The provider recommends the excision of the lesion to relieve the patient’s discomfort and enhance their visual function.
5. A conjunctival lesion measuring 1.5 cm in size is causing pain and pressure for a patient. The provider decides to perform an excision to alleviate the patient’s symptoms and improve their overall eye health.
6. During a routine eye check-up, a provider identifies a conjunctival lesion measuring 1.3 cm in size. The provider recommends the excision of the lesion to alleviate the patient’s discomfort and prevent any further complications.
7. A patient presents with a conjunctival lesion measuring 1.7 cm in size. The provider determines that the excision of the lesion is necessary to alleviate the patient’s symptoms and improve their visual acuity.
8. After a comprehensive examination, a provider diagnoses a patient with a conjunctival lesion measuring 1.4 cm in size. The provider decides to perform an excision to relieve the patient’s discomfort and enhance their overall eye health.
9. A conjunctival lesion measuring 1.6 cm in size is causing pain and pressure for a patient. The provider recommends the excision of the lesion to alleviate the patient’s symptoms and prevent any further complications.
10. During a routine eye check-up, a provider identifies a conjunctival lesion measuring 1.9 cm in size. The provider determines that the excision of the lesion is necessary to alleviate the patient’s discomfort and improve their visual function.