How To Use CPT Code 68540

CPT 68540 describes the excision of a tumor from the lacrimal gland using a frontal approach. 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 68540?

CPT 68540 is used to describe the excision of a tumor from the lacrimal gland using a frontal approach. This procedure is performed to treat obstruction or blockage in the lacrimal gland and prevent further complications. The tumor is removed and sent to the laboratory for diagnostic analysis.

2. Official Description

The official description of CPT code 68540 is: ‘Excision of lacrimal gland tumor; frontal approach.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the soft tissues around the orbit of the eye.
3. The incision is carried down through subcutaneous tissues and muscle to the outer covering of the orbital bone.
4. The provider lifts up the outer covering of the orbital bone to expose the tumor.
5. The tumor, along with the lacrimal gland, is excised.
6. The excised tumor is sent to the laboratory for diagnostic analysis.
7. The provider drills holes in the frontal process of the zygomatic bone and in the stable bone on both sides of where the bone was removed.
8. Wires or screws are used to affix the bone back in place.
9. The wounds in the internal tissues are closed.
10. The provider checks for bleeding, removes all instruments, and closes the skin incision.

4. Qualifying circumstances

CPT 68540 is performed when there is a tumor in the lacrimal gland that requires excision. The procedure is indicated to treat obstruction or blockage in the lacrimal gland and prevent further complications. The patient must have a diagnosis of a lacrimal gland tumor, and the excision must be performed using a frontal approach.

5. When to use CPT code 68540

CPT code 68540 should be used when a tumor is present in the lacrimal gland and requires excision using a frontal approach. It is important to accurately document the diagnosis and the approach used during the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 68540, the following documentation is required:

• Patient’s diagnosis of a lacrimal gland tumor
• Description of the frontal approach used during the excision
• Date of the procedure
• Details of the excision, including any additional procedures performed
• Documentation of the tumor sent to the laboratory for diagnostic analysis
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 68540, ensure that the excision is performed using a frontal approach. It is important to accurately document the procedure and provide the necessary supporting documentation. CPT code 68540 should not be reported with other codes unless additional procedures were performed during the same session.

8. Historical information

CPT 68540 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 excision of a lacrimal gland tumor using a frontal approach to treat obstruction and prevent further complications.
2. A provider performs the excision of a lacrimal gland tumor using a frontal approach and sends the tumor to the laboratory for diagnostic analysis.
3. A lacrimal gland tumor is excised using a frontal approach, and the provider affixes the bone back in place using wires or screws.
4. A patient with a diagnosis of a lacrimal gland tumor undergoes excision using a frontal approach, and the wounds are closed after checking for bleeding.
5. A provider performs the excision of a lacrimal gland tumor using a frontal approach and documents the details of the procedure and the tumor sent to the laboratory for analysis.
6. A lacrimal gland tumor is excised using a frontal approach, and the provider ensures all instruments are removed and closes the skin incision.
7. A patient undergoes excision of a lacrimal gland tumor using a frontal approach, and the provider drills holes in the frontal process of the zygomatic bone and in the stable bone for bone fixation.
8. A provider performs the excision of a lacrimal gland tumor using a frontal approach and closes the wounds in the internal tissues.
9. A lacrimal gland tumor is excised using a frontal approach, and the provider accurately documents the diagnosis and approach used during the procedure.
10. A patient with a diagnosis of a lacrimal gland tumor undergoes excision using a frontal approach, and the provider signs the documentation to support the procedure performed.