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A scleral staphyloma refers to a protrusion of uveal tissue through a compromised area of the sclera or cornea, often resulting from prior injury, disease, or inflammation. This condition can manifest in various forms, depending on the location of the protrusion within the eye. There are five recognized types of staphylomas: anterior segment staphylomas, which affect the cornea and surrounding scleral tissue; intercalary or limbal staphylomas, located at the junction of the cornea and sclera, frequently associated with secondary angle closure glaucoma or corneal astigmatism; ciliary staphylomas, found near the ciliary bodies approximately 2-3 mm from the limbus; equatorial staphylomas, which occur in areas perforated by vortex veins; and posterior or macular staphylomas, situated at the back of the eye and typically diagnosed through ophthalmoscopy, often after the patient presents with myopia. The procedure described by CPT® Code 66225 involves the excision of the protruding uveal tissue and the reinforcement of the weakened scleral area using a tissue graft, such as an allogenic fascial graft, which is secured in place with fibrin tissue glue. This surgical intervention aims to restore the structural integrity of the eye and prevent further complications associated with staphylomas.
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The procedure described by CPT® Code 66225 is indicated for patients presenting with scleral staphylomas, which may arise due to various underlying conditions. The following are specific indications for performing this surgical repair:
The surgical procedure for CPT® Code 66225 involves several critical steps to effectively repair the scleral staphyloma:
After the completion of the procedure, patients are typically monitored for any immediate complications. Post-operative care may include the use of topical antibiotics to prevent infection and anti-inflammatory medications to reduce swelling. Patients are advised to avoid strenuous activities and to follow up with their ophthalmologist for regular assessments of healing and visual function. The expected recovery period may vary depending on individual circumstances, but patients should be informed about potential signs of complications, such as increased pain, redness, or vision changes, that would necessitate prompt medical attention.
| Short Descr | REPAIR/GRAFT EYE LESION | Medium Descr | REPAIR SCLERAL STAPHYLOMA W/GRAFT | Long Descr | Repair of scleral staphyloma with graft | 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 |
| 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). | 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.) | 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) |
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| 2019-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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