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Keratoplasty, specifically endothelial keratoplasty, is a surgical procedure aimed at replacing the damaged endothelial layer of the cornea, which is crucial for maintaining corneal clarity and overall eye health. This procedure is particularly beneficial for patients suffering from endothelial dysfunction, a condition that can lead to corneal swelling and vision impairment. The two primary techniques employed in endothelial keratoplasty are deep lamellar endothelial keratoplasty (DLEK) and Descemet's stripping endothelial keratoplasty (DSEK). DLEK involves the dissection and removal of the posterior corneal stroma, while DSEK focuses on stripping the Descemet's membrane to facilitate the transplantation of a donor lenticule. Both techniques require precise surgical maneuvers, including the creation of a scleral tunnel and the careful placement of the donor tissue into the anterior chamber of the eye. The use of viscoelastic substances, such as Healon, is critical during the procedure to maintain the anterior chamber's structure and facilitate the smooth insertion of the donor lenticule. Overall, endothelial keratoplasty is a vital intervention for restoring vision in patients with specific corneal pathologies, ensuring that the cornea remains clear and functional.
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The procedure of endothelial keratoplasty is indicated for several specific conditions that affect the endothelial layer of the cornea. These include:
The procedure for endothelial keratoplasty involves several critical steps that ensure the successful transplantation of the donor corneal tissue. The process begins with the incision of the conjunctival tissue around the entire circumference of the cornea, known as peritomy, using surgical scissors and forceps. Following this, a 5 mm scleral tunnel is created, starting 1.5 mm from the limbus, which serves as an access point for the procedure. Paracentesis is performed on each side of the scleral tunnel to facilitate fluid management during the surgery. The anterior chamber is then filled with a viscoelastic substance, such as Healon, to maintain its structure and protect the corneal tissues during manipulation.
If the deep lamellar endothelial keratoplasty (DLEK) technique is employed, the posterior corneal stroma is carefully dissected away. A keratome is then used to enter the anterior chamber, allowing for the removal of the posterior cornea through scissor dissection. After this, the Healon is removed from the anterior chamber using irrigation and aspiration techniques. A temporary suture is placed in the scleral tunnel to secure the structure while the donor lenticule is prepared. The donor tissue is folded and grasped with forceps, and the temporary suture is removed to allow for the placement of the donor lenticule into the anterior chamber. Once positioned, the scleral tunnel is closed, and the lenticule is unfolded by injecting air into the anterior chamber. The lenticule is then tucked into place using surgical hooks, the anterior chamber is filled with balanced saline solution, and the conjunctiva is subsequently closed.
In the case of the Descemet's stripping endothelial keratoplasty (DSEK) technique, the procedure begins with scoring the Descemet's membrane using a Sinskey hook, followed by stripping it away with a hook, strippers, or an irrigation/aspiration device. The edge of the membrane is roughened to facilitate the attachment of the donor lenticule. The prepared lenticule is then folded and placed into the anterior chamber, similar to the DLEK technique. After closing the scleral tunnel, the lenticule is unfolded and positioned by infiltrating air into the anterior chamber, ensuring proper placement. Any excess fluid is massaged out of the interface to promote adherence, and the pupil is dilated before the conjunctiva is closed to complete the procedure.
Post-procedure care following endothelial keratoplasty is essential for optimal recovery and includes monitoring for any signs of complications such as infection or graft rejection. Patients are typically advised to use prescribed topical medications, including antibiotics and corticosteroids, to reduce inflammation and prevent infection. Regular follow-up appointments are necessary to assess the healing process and the clarity of the cornea. Patients may experience some discomfort or visual fluctuations during the initial recovery phase, which is expected as the cornea heals and the donor tissue integrates. It is crucial for patients to adhere to their post-operative care instructions and attend all follow-up visits to ensure the best possible outcome from the procedure.
| Short Descr | CORNEAL TRNSPL ENDOTHELIAL | Medium Descr | KERATOPLASTY ENDOTHELIAL | Long Descr | Keratoplasty (corneal transplant); endothelial | 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 | Non office-based surgical procedure added in CY 2008 or later; 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 |
This is a primary code that can be used with these additional add-on codes.
| 65757 | Addon Code MPFS Status: Carrier Priced APC N ASC N1 CPT Assistant Article Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure) |
| RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | 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.) | SG | Ambulatory surgical center (asc) facility service | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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.) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | 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. | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 55 | Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number. | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GW | Service not related to the hospice patient's terminal condition | KX | Requirements specified in the medical policy have been met | X3 | Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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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| 2011-01-01 | Changed | Short description changed. |
| 2009-01-01 | Added | - |
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