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Keratoplasty, specifically referred to as penetrating keratoplasty in the context of aphakia, is a surgical procedure aimed at enhancing visual acuity by replacing the damaged or diseased corneal tissue with healthy corneal tissue obtained from a donor. This procedure is particularly indicated for patients who have experienced significant corneal opacification or other corneal pathologies that impair vision. During the operation, the surgeon utilizes an operating microscope to achieve a high level of precision and visualization of the eye's structures. A specialized instrument known as a trephine is employed to excise a circular segment of the patient's cornea, which is then replaced with a similarly shaped piece of donor cornea, ensuring that the epithelial side is oriented correctly towards the recipient's eye. Following the placement of the donor tissue, it is secured in position using sutures. To facilitate healing and prevent infection, antibiotic eye drops may be administered, and the eye is typically protected with a patch or shield post-operatively. This code, CPT® 65750, specifically encompasses penetrating keratoplasty performed in cases of corneal edema that may arise following cataract extraction, distinguishing it from other related procedures such as CPT® 65755, which pertains to cases involving a pseudophakia intraocular lens.
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The procedure of penetrating keratoplasty (CPT® 65750) is indicated for patients experiencing specific conditions that necessitate the replacement of corneal tissue. These indications include:
The procedure of penetrating keratoplasty involves several critical steps to ensure successful transplantation of the corneal tissue. These steps include:
Post-procedure care is essential for optimal recovery following penetrating keratoplasty. Patients are typically advised to follow specific instructions, which may include the use of prescribed antibiotic and anti-inflammatory eye drops to reduce the risk of infection and inflammation. Regular follow-up appointments are necessary to monitor the healing process and assess the integration of the donor tissue. Patients may experience some discomfort, blurred vision, or sensitivity to light during the initial recovery period. It is crucial to avoid any activities that could strain the eye, such as heavy lifting or vigorous exercise, until cleared by the healthcare provider. The duration of the recovery period can vary, but patients are generally advised to expect gradual improvement in vision over several weeks to months as the eye heals.
| Short Descr | CORNEAL TRANSPLANT | Medium Descr | KERATOPLASTY PENETRAING APHAKIA | Long Descr | Keratoplasty (corneal transplant); penetrating (in aphakia) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P4A - Eye procedure - corneal transplant | MUE | 1 | CCS Clinical Classification | 13 - Corneal transplant |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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