How To Use CPT Code 68325

CPT 68325 describes a surgical procedure that involves the repair of the conjunctiva using a tissue graft from the patient’s cheek. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 68325?

CPT 68325 can be used to describe a surgical procedure in which the provider performs a conjunctivoplasty using a buccal mucous membrane graft. This procedure is typically performed to treat conditions such as conjunctivochalasis, which is characterized by excess folds of conjunctiva in the eye.

2. Official Description

The official description of CPT code 68325 is: ‘Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft).’ This procedure involves the surgical repair of the conjunctiva using a tissue graft from the patient’s cheek.

3. Procedure

1. The provider administers a local anesthetic to the patient and prepares the surgical site.
2. Using an operating microscope or loupe magnification, the provider identifies the areas of loose conjunctiva that need to be relaxed.
3. The provider excises a small strip of conjunctival tissue from the underlying tissue, ensuring that enough healthy conjunctiva adjacent to the cornea is left.
4. A tissue graft is obtained from the patient’s cheek, specifically the buccal mucous membrane.
5. The provider prepares the wound location for the graft and trims the harvested tissue to match the size of the defect.
6. The graft is secured underneath the conjunctiva using sutures or tissue adhesive.
7. A pressure patch with antibiotic ointment is applied to complete the procedure.

4. Qualifying circumstances

CPT 68325 is typically performed on patients with conjunctivochalasis or other conditions that require the relaxation of folded conjunctival tissue. The procedure is performed by a qualified healthcare provider under a local anesthetic. The provider must ensure that enough healthy conjunctiva adjacent to the cornea is left after excising the conjunctival tissue.

5. When to use CPT code 68325

CPT code 68325 should be used when a conjunctivoplasty is performed with a buccal mucous membrane graft. It is important to accurately document the procedure and ensure that the patient meets the qualifying circumstances for this code.

6. Documentation requirements

To support a claim for CPT 68325, the provider must document the following information:

• Patient’s diagnosis and the need for conjunctivoplasty
• Details of the procedure, including the use of a buccal mucous membrane graft
• Date of the procedure
• Start and end time of the procedure
• Any additional relevant information, such as the size of the defect and the number of sutures used
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 68325, ensure that the procedure meets the requirements outlined in the official description. It is important to accurately document the procedure and use the appropriate modifiers if necessary. Additionally, be aware of any specific guidelines or requirements from the payer when reporting this code.

8. Historical information

CPT 68325 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 patient undergoes a conjunctivoplasty with a buccal mucous membrane graft to treat conjunctivochalasis.
2. A provider performs a conjunctivoplasty with a buccal mucous membrane graft to address excessive folds of conjunctiva in a patient’s eye.
3. A conjunctivoplasty with a buccal mucous membrane graft is performed on a patient with a specific diagnosis requiring this procedure.
4. A provider uses a buccal mucous membrane graft during a conjunctivoplasty to relax folded conjunctival tissue in a patient’s eye.
5. A patient undergoes a conjunctivoplasty with a buccal mucous membrane graft to improve their ocular comfort and vision.
6. A provider performs a conjunctivoplasty with a buccal mucous membrane graft to address functional issues caused by excess conjunctival tissue.
7. A conjunctivoplasty with a buccal mucous membrane graft is performed on a patient with a specific medical condition requiring this surgical intervention.
8. A provider uses a buccal mucous membrane graft during a conjunctivoplasty to achieve optimal results in a patient’s eye.
9. A patient undergoes a conjunctivoplasty with a buccal mucous membrane graft to alleviate discomfort and improve the overall health of their eye.
10. A provider performs a conjunctivoplasty with a buccal mucous membrane graft to address cosmetic concerns and functional issues in a patient’s eye.