How To Use CPT Code 68525

CPT 68525 describes the procedure for taking a biopsy of the lacrimal sac, which is the upper dilated end of the tear duct. 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 68525?

CPT 68525 involves the biopsy of the lacrimal sac, which is the upper dilated end of the tear duct. This procedure is performed to rule out or diagnose any pathology in the lacrimal sac tissue. It is important to note that this code should not be reported if the provider performs both the biopsy and the excision of the lacrimal sac in the same surgical session.

2. Official Description

The official description of CPT code 68525 is: ‘Biopsy of lacrimal sac.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision directly over the lacrimal sac, just lateral to the lacrimal crest.
3. The provider deepens the incision bluntly.
4. The provider makes an incision to dissect the medial canthal tendon from its insertion on the lacrimal sac.
5. A piece of the lacrimal sac is removed and sent to the laboratory for biopsy investigation.
6. The provider closes the skin incision with sutures.

4. Qualifying circumstances

CPT 68525 is performed when there is a need to take a biopsy of the lacrimal sac to rule out or diagnose any pathology. This procedure is typically performed by a provider who is experienced in lacrimal system procedures. It is important to note that if the provider performs both the biopsy and the excision of the lacrimal sac in the same surgical session, CPT code 68525 should not be reported.

5. When to use CPT code 68525

CPT code 68525 should be used when the provider performs a biopsy of the lacrimal sac. It should not be reported if the provider performs both the biopsy and the excision of the lacrimal sac in the same surgical session.

6. Documentation requirements

To support a claim for CPT 68525, the provider must document the following information:

• Reason for the biopsy and the need to rule out or diagnose any pathology
• Details of the procedure, including the incision location and closure method
• Documentation of the biopsy sample sent to the laboratory for investigation

7. Billing guidelines

When billing for CPT 68525, ensure that the procedure is performed by a provider experienced in lacrimal system procedures. It is important to note that CPT code 68525 should not be reported if the provider performs both the biopsy and the excision of the lacrimal sac in the same surgical session.

8. Historical information

CPT 68525 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 undergoes a biopsy of the lacrimal sac to investigate a suspected pathology.
2. A provider performs a lacrimal sac biopsy to rule out any abnormalities in a patient with chronic tearing.
3. A biopsy of the lacrimal sac is performed on a patient with recurrent infections to determine the underlying cause.
4. A lacrimal sac biopsy is performed on a patient with a history of trauma to assess for any damage or abnormalities.
5. A provider performs a biopsy of the lacrimal sac to investigate a suspected tumor in a patient.
6. A lacrimal sac biopsy is performed on a patient with persistent eye discharge to determine the cause.
7. A patient undergoes a biopsy of the lacrimal sac to investigate a suspected infection.
8. A provider performs a lacrimal sac biopsy to rule out any abnormalities in a patient with chronic eye irritation.
9. A biopsy of the lacrimal sac is performed on a patient with a history of recurrent dacryocystitis to assess for any underlying causes.
10. A lacrimal sac biopsy is performed on a patient with a suspected lacrimal system obstruction to determine the cause.