How To Use CPT Code 68360

CPT code 68360 describes a surgical procedure involving the creation of a conjunctival flap to cover a site adjacent to a defect. This article will provide an overview of CPT 68360, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 68360?

CPT 68360 is a surgical procedure that involves the creation of a conjunctival flap. This flap is made from free conjunctival tissue and is used to cover a site next to a defect, such as a portion of a diseased cornea. The procedure is performed by a healthcare provider under local anesthesia and involves the use of microsurgical techniques.

2. Official Description

The official description of CPT code 68360 is: ‘Conjunctival flap; bridge or partial (separate procedure).’ This code represents the creation of a flap using free conjunctival tissue to cover a site adjacent to a defect.

3. Procedure

1. The healthcare provider begins by placing an ocular speculum in the patient’s eye to keep it open during the procedure.
2. Using an operating microscope and microsurgical techniques, the provider prepares the recipient site and evaluates the most suitable location for obtaining a conjunctival segment.
3. The provider then elevates the conjunctiva from the underlying tissue and creates a free flap by undermining a small strip of conjunctiva.
4. The incision is extended until the mobilized partial free flap can be placed over the adjacent defect without tension.
5. Once the flap is in position, the provider secures it with sutures.
6. After completing the procedure, the provider applies antibiotic ointment and patches the eye.

4. Qualifying circumstances

CPT 68360 is performed when there is a need to cover a site adjacent to a defect, such as a portion of a diseased cornea, using a conjunctival flap. The procedure is typically performed by a healthcare provider under local anesthesia and requires the use of microsurgical techniques.

5. When to use CPT code 68360

CPT code 68360 should be used when a healthcare provider performs a conjunctival flap procedure to cover a site adjacent to a defect. It is important to note that this code represents a separate procedure and should not be reported if it is performed as part of another procedure.

6. Documentation requirements

To support a claim for CPT code 68360, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the conjunctival flap procedure
• Details of the procedure, including the use of microsurgical techniques
• Date of the procedure
• Start and end time of the procedure
• Location of the defect and the site where the conjunctival flap was placed
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 68360, ensure that the procedure meets the criteria for a conjunctival flap procedure to cover a site adjacent to a defect. It is important to use the appropriate modifier if the procedure is performed on a specific eyelid. Additionally, be aware of any specific guidelines or requirements from the payer regarding the use of CPT code 68360.

8. Historical information

CPT code 68360 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 a conjunctival flap procedure to cover a portion of a diseased cornea in a patient with keratoconus.
2. During a surgical procedure, a conjunctival flap is created to cover a site adjacent to a defect caused by trauma to the eye.
3. A patient with a corneal ulcer undergoes a conjunctival flap procedure to promote healing and protect the affected area.
4. A healthcare provider performs a conjunctival flap procedure to cover a site adjacent to a defect in a patient with a corneal perforation.
5. During a surgical intervention, a conjunctival flap is created to cover a site adjacent to a defect in a patient with a corneal infection.
6. A healthcare provider performs a conjunctival flap procedure to cover a portion of a diseased cornea in a patient with corneal dystrophy.
7. During a surgical procedure, a conjunctival flap is created to cover a site adjacent to a defect caused by a corneal ulcer.
8. A patient with a corneal scar undergoes a conjunctival flap procedure to improve vision and protect the affected area.
9. A healthcare provider performs a conjunctival flap procedure to cover a site adjacent to a defect in a patient with a corneal abrasion.
10. During a surgical intervention, a conjunctival flap is created to cover a site adjacent to a defect in a patient with a corneal tumor.