Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
Scleral reinforcement is a surgical procedure aimed at addressing high myopia, a condition characterized by severe nearsightedness that can lead to complications such as damage to the macula. This procedure is performed as a separate intervention and is designed to prevent further deterioration of the eye's structure and function. During the operation, a lid speculum is utilized to hold the eyelids open, providing the surgeon with a clear view of the eye. Local anesthesia is administered to ensure patient comfort throughout the procedure. The surgical approach involves making an incision in the conjunctiva and Tenon's capsule, which are layers of tissue surrounding the eye, approximately 6 mm from the corneal limbus. The lateral, superior, and inferior recti muscles, which control eye movement, are carefully separated using a specialized instrument known as a strabismus hook. This allows access to the posterior pole of the eye, where connective tissue is meticulously dissected away from the inferior oblique muscle. In the context of CPT® Code 67250, the sclera is reinforced without the use of a graft. This process includes creating an indentation in the posterior aspect of the sclera, which is achieved by oversewing the weakened area with a thick piece of rubber or sponge material. This technique causes the posterior region of the sclera to indent or buckle, providing structural support. Additionally, a strip of synthetic material may be employed to create a sling that further supports the posterior sclera. This sling is positioned beneath the separated muscles along the posterior pole and is sutured to the anteromedial and anterolateral sclera, enhancing the stability of the eye's structure. This procedure is distinct from CPT® Code 67255, which involves the use of a graft for scleral reinforcement.
© Copyright 2026 Coding Ahead. All rights reserved.
The scleral reinforcement procedure is indicated for patients suffering from high myopia, which is a significant refractive error that can lead to various ocular complications. The primary goal of this procedure is to prevent damage to the macula, a critical area of the retina responsible for central vision. High myopia can result in thinning of the sclera and other structural weaknesses, making individuals susceptible to retinal detachment and other serious vision-threatening conditions.
The scleral reinforcement procedure involves several critical steps to ensure effective treatment of high myopia. Initially, a lid speculum is employed to hold the eyelids open, allowing the surgeon unobstructed access to the eye. Following this, local anesthesia is administered to ensure the patient remains comfortable throughout the procedure. The surgeon then makes an incision in the conjunctiva and Tenon's capsule, approximately 6 mm from the corneal limbus, to access the underlying structures of the eye.
After the scleral reinforcement procedure, patients typically require monitoring 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 their recovery. The expected recovery period may vary, but patients should be informed about potential symptoms such as discomfort or changes in vision, which should be reported to their healthcare provider promptly. Overall, the procedure aims to stabilize the eye's structure and prevent further complications associated with high myopia.
| Short Descr | REINFORCE EYE WALL | Medium Descr | SCLERAL REINFORCEMENT SPX W/O GRAFT | Long Descr | Scleral reinforcement (separate procedure); without 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). | 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.) | 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 | 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 | 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 |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.