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The CPT® Code 68115 refers to the excision of a lesion from the conjunctiva that measures over 1 cm. Conjunctival lesions can vary in nature, with some of the more common types requiring excision being benign squamous cell lesions and limbal papillomas, as well as malignant conditions such as primary acquired melanosis, conjunctival melanoma, and squamous cell carcinoma. The procedure typically begins with the administration of anesthetic drops or another form of local anesthesia to ensure patient comfort during the excision. Following anesthesia, the conjunctiva is carefully inspected to assess the lesion and determine the extent of the excision required. The surgeon excises the lesion along with a margin of healthy tissue to ensure complete removal. The excised tissue is then sent for pathological evaluation to confirm the diagnosis and to check that the margins are clear of any remaining abnormal cells. If necessary, additional tissue, including scleral tissue, may be excised until clear margins are achieved. It is important to note that for lesions measuring up to 1 cm, the appropriate code is 68110, while for lesions requiring excision of adjacent scleral tissue, the code 68130 should be used.
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The excision of conjunctival lesions, as described by CPT® Code 68115, is indicated for various conditions that may affect the conjunctiva. These include:
The procedure for excising a conjunctival lesion over 1 cm involves several critical steps to ensure successful removal and patient safety. The first step is the administration of anesthetic drops or another form of local anesthesia to numb the area around the eye, allowing the patient to remain comfortable throughout the procedure. Following anesthesia, the surgeon conducts a thorough inspection of the conjunctiva to assess the lesion's characteristics and determine the appropriate extent of excision required. This assessment is crucial for planning the surgical approach.
After the excision of the conjunctival lesion, patients may require specific post-procedure care to promote healing and prevent complications. It is essential to monitor the surgical site for any signs of infection or unusual symptoms. Patients are typically advised to avoid rubbing or touching the eye and to follow any prescribed medication regimen, which may include antibiotic eye drops to prevent infection. Follow-up appointments are crucial to assess the healing process and to review the results of the pathological evaluation. The expected recovery time may vary depending on the individual and the extent of the excision, but most patients can expect to resume normal activities within a few days, provided there are no complications. Additionally, patients should be informed about potential signs of complications, such as increased redness, swelling, or discharge from the eye, which would necessitate immediate medical attention.
| Short Descr | EXC LES CONJUNCTIVA >1 CM | Medium Descr | EXCISION LESION CONJUNCTIVA > 1 CM | Long Descr | Excision of lesion, conjunctiva; over 1 cm | Status Code | Active Code | Global Days | 010 - 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 | 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) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 19 - Other therapeutic procedures on eyelids, conjunctiva, cornea |
| 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) | 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). | E2 | Lower left, eyelid | 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. | 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. | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | E1 | Upper left, eyelid | E3 | Upper right, eyelid | E4 | Lower right, eyelid | 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 | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | SG | Ambulatory surgical center (asc) facility service | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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