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The procedure described by CPT® Code 65865 involves the surgical severing of adhesions located in the anterior segment of the eye, specifically utilizing an incisional technique. This procedure may be performed with or without the injection of air or liquid to assist in stabilizing intraocular pressure. The primary focus of this procedure is on goniosynechiae, which are pathological adhesions that occur between the iris and the posterior surface of the cornea within the iridocorneal angle of the anterior chamber. Goniosynechiae are often associated with angle closure glaucoma, a condition that can lead to increased intraocular pressure and potential vision loss if not addressed. During the procedure, an incision is made in the cornea, and a specialized instrument, such as a needle or knife blade, is employed to carefully sever the adhesive tissue that connects the iris to the cornea. This action aims to restore normal anatomical relationships and improve the function of the anterior segment of the eye. In cases where aqueous fluid is lost during the procedure, the injection of air or liquid may be necessary to maintain appropriate pressure within the eye, thereby preventing complications. It is important to note that this procedure is distinct from other related procedures, such as those described by CPT® Codes 65870, 65875, and 65880, which address different types of adhesions within the eye. Overall, CPT® Code 65865 is a critical intervention for managing specific types of ocular adhesions that can significantly impact patient vision and eye health.
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The procedure associated with CPT® Code 65865 is indicated for the treatment of specific conditions related to adhesions in the anterior segment of the eye. The following indications are explicitly recognized for this procedure:
The procedure for CPT® Code 65865 involves several critical steps to effectively sever the adhesions in the anterior segment of the eye. The procedural steps are as follows:
Following the procedure associated with CPT® Code 65865, patients are typically monitored for any signs of complications, such as increased intraocular pressure or infection. Post-procedure care may include the use of topical medications, such as antibiotics or anti-inflammatory agents, to promote healing and prevent infection. Patients are advised to follow up with their ophthalmologist to assess the success of the procedure and to monitor for any recurrence of adhesions or other complications. Recovery time may vary depending on the individual patient's condition and the extent of the procedure performed.
| Short Descr | INCISE INNER EYE ADHESIONS | Medium Descr | SEVERING ADS ANT SEG INCAL TQ SPX GONIOSYNECHIAE | Long Descr | Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae | 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) | 1 - Statutory payment restriction for assistants at surgery applies 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) | P4E - Eye procedure - other | MUE | 1 | CCS Clinical Classification | 20 - Other intraocular therapeutic procedures |
| LT | Left side (used to identify procedures performed on the left side of the body) | 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). | RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 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. | 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.) | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | SG | Ambulatory surgical center (asc) facility service | 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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| Pre-1990 | Added | Code added. |
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