How To Use CPT Code 68400

CPT 68400 describes the procedure of incision and drainage of the lacrimal gland. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 68400?

CPT 68400 involves the incision and drainage of the lacrimal gland, which is responsible for secreting the aqueous layer of the tear film. This procedure is performed by a healthcare provider when the patient is properly prepped and anesthetized. The provider makes an incision and drains the lacrimal gland, located above and at the outer corner of the eye. Antibiotics may be applied, and the incision can be left open or closed with a drain.

2. Official Description

The official description of CPT code 68400 is the incision and drainage of the lacrimal gland. This procedure involves making an incision and draining the gland, which secretes the aqueous layer of the tear film. The provider may also apply antibiotics and choose to leave the incision open or closed with a drain.

3. Procedure

1. After proper patient preparation and anesthesia, the healthcare provider makes an incision in the lacrimal gland.
2. The provider then drains the gland, which is responsible for secreting the aqueous layer of the tear film.
3. Antibiotics may be applied to prevent infection.
4. The provider can choose to leave the incision open or close it with a drain.

4. Qualifying circumstances

CPT 68400 is performed when the patient requires incision and drainage of the lacrimal gland. This procedure is typically indicated when there is a need to address issues related to the gland’s function or to treat conditions affecting the tear film. The healthcare provider must ensure that the patient is appropriately prepped and anesthetized before performing the procedure.

5. When to use CPT code 68400

CPT code 68400 should be used when the healthcare provider performs the incision and drainage of the lacrimal gland. It is important to note that this code should only be used for this specific procedure and not for any other related procedures or interventions.

6. Documentation requirements

To support a claim for CPT 68400, the healthcare provider must document the following information:

• Patient’s diagnosis or condition necessitating the incision and drainage of the lacrimal gland
• Details of the procedure, including the incision and drainage technique used
• Any additional interventions performed, such as the application of antibiotics or the use of a drain
• Any complications or adverse events that occurred during or after the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 68400, ensure that the procedure performed is the incision and drainage of the lacrimal gland. It is important to follow the appropriate coding guidelines and ensure accurate documentation to support the claim. CPT code 68400 should not be reported with other codes unless there are distinct and separate procedures performed. It is crucial to review the payer’s guidelines and policies to ensure proper reimbursement.

8. Historical information

CPT code 68400 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 an incision and drainage of the lacrimal gland to address a chronic infection in a patient.
2. During a surgical procedure, the lacrimal gland is incised and drained to relieve a blockage in the tear duct.
3. A patient with a lacrimal gland abscess undergoes an incision and drainage procedure to remove the accumulated fluid.
4. As part of a treatment plan for a tear film disorder, the lacrimal gland is incised and drained to improve tear production.
5. A healthcare provider performs an incision and drainage of the lacrimal gland to address a persistent inflammation in a patient.
6. During a surgical intervention, the lacrimal gland is incised and drained to alleviate symptoms of excessive tearing.
7. A patient with a lacrimal gland cyst undergoes an incision and drainage procedure to remove the cystic fluid.
8. As part of a diagnostic evaluation, the lacrimal gland is incised and drained to collect a sample for further analysis.
9. A healthcare provider performs an incision and drainage of the lacrimal gland to treat a recurrent infection in a patient.
10. During a surgical procedure, the lacrimal gland is incised and drained to address a tumor or growth in the gland.