How To Use CPT Code 68510

CPT 68510 describes the procedure for the biopsy of the lacrimal gland, which involves removing a portion or the entirety of suspicious tissue for pathologic examination. 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 68510?

CPT 68510 is used to describe the biopsy of the lacrimal gland, which is performed to remove a portion or the entirety of suspicious tissue for pathologic examination. This procedure involves making an incision to expose the lacrimal gland, biopsying a suspicious area, and closing the wound in layers. The specimen is then sent to the laboratory for examination.

2. Official Description

The official description of CPT code 68510 is: ‘The provider biopsies the lacrimal gland and sends the specimen to the laboratory for pathologic examination.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision to expose the lacrimal gland.
3. A suspicious area is biopsied.
4. The specimen is sent to pathology for examination.
5. The wound is closed in layers.
6. The patient is released after a brief period of observation.

4. Qualifying circumstances

CPT 68510 is performed when there is a need to biopsy the lacrimal gland due to suspicion of abnormal tissue. The procedure is typically done when there are signs or symptoms of a lacrimal gland disorder or when imaging studies indicate the presence of a suspicious area. The patient must be appropriately prepped and anesthetized, and the provider must have the necessary skills and qualifications to perform the biopsy.

5. When to use CPT code 68510

CPT code 68510 should be used when a biopsy of the lacrimal gland is performed to remove suspicious tissue for pathologic examination. It is important to ensure that the procedure meets the specific criteria outlined in the code description and that the documentation supports the medical necessity of the biopsy.

6. Documentation requirements

To support a claim for CPT 68510, the provider must document the following information:

• Reason for the biopsy and the presence of suspicious tissue
• Details of the procedure, including the incision, biopsy, and closure
• Pathologic examination request and specimen handling
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the biopsy

7. Billing guidelines

When billing for CPT 68510, ensure that the procedure meets the specific criteria outlined in the code description. It is important to use the appropriate diagnosis code to support the medical necessity of the biopsy. Additionally, consider any applicable modifiers or additional codes that may be required for accurate billing. It is also important to review any specific billing guidelines provided by payers to ensure compliance with their requirements.

8. Historical information

CPT 68510 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 suspicious mass in the lacrimal gland. The provider performs a biopsy of the gland to obtain a tissue sample for pathologic examination.
2. During a routine eye examination, the provider notices an abnormality in the lacrimal gland. A biopsy is performed to further evaluate the tissue and determine the presence of any pathology.
3. A patient with a history of lacrimal gland disorder experiences worsening symptoms. The provider decides to perform a biopsy to assess the underlying cause of the symptoms and guide further treatment.
4. Following imaging studies, a suspicious area is identified in the lacrimal gland. The provider performs a biopsy to obtain a tissue sample for pathologic examination and confirm the presence of any abnormalities.
5. A patient presents with persistent swelling and pain in the lacrimal gland. The provider decides to perform a biopsy to investigate the underlying cause of the symptoms and determine the appropriate course of treatment.