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.
The procedure described by CPT® Code 68040 refers to the expression of conjunctival follicles, which is a targeted intervention primarily aimed at treating follicular conjunctivitis. This condition is characterized by the presence of swollen, inflamed follicles on the conjunctiva, often resulting from infections, with Chlamydia trachomatis being a common causative agent. The expression of these follicles is essential for alleviating symptoms associated with the infection, such as discomfort, redness, and discharge. During the procedure, local anesthetic drops may be administered to minimize discomfort for the patient. The eyelid is then everted, allowing for a clear view of the conjunctival surface where the follicles are located. By applying manual pressure, the clinician can effectively express any purulent material contained within the follicles, thereby facilitating drainage and promoting healing. This procedure is particularly important in managing cases of follicular conjunctivitis that do not respond adequately to conservative treatments.
© Copyright 2026 Coding Ahead. All rights reserved.
The expression of conjunctival follicles is indicated for the treatment of follicular conjunctivitis, particularly in cases where the condition is caused by a viral or bacterial infection. The following specific indications are associated with this procedure:
The procedure for the expression of conjunctival follicles involves several key steps that ensure effective treatment of follicular conjunctivitis. Each step is crucial for achieving the desired outcome.
After the procedure, patients may experience some temporary discomfort or irritation in the treated eye. It is important to monitor for any signs of complications, such as increased redness or discharge. Patients are typically advised to follow up with their healthcare provider to assess the effectiveness of the procedure and to determine if any further treatment is necessary. Additionally, proper eye care and hygiene should be emphasized to prevent recurrence of infection.
| Short Descr | TREATMENT OF EYELID LESIONS | Medium Descr | EXPRESSION CONJUNCTIVAL FOLLICLES | Long Descr | Expression of conjunctival follicles (eg, for trachoma) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | 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) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 19 - Other therapeutic procedures on eyelids, conjunctiva, cornea |
| 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). | 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.) | E2 | Lower left, eyelid | 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.) | E1 | Upper left, eyelid | E3 | Upper right, eyelid | E4 | Lower right, eyelid | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.