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The procedure described by CPT® Code 68335 involves the surgical repair of a symblepharon, which is a condition characterized by the abnormal adhesion or scar tissue formation between the palpebral conjunctiva (the inner lining of the eyelid) and the bulbar conjunctiva (the membrane covering the eyeball). This condition often arises as a result of trauma or infection and can lead to significant complications, including restricted eye movement, incomplete eyelid closure, and double vision. The repair process for a symblepharon under this code includes the use of a free graft, which can be either conjunctival tissue or buccal mucous membrane, to effectively address the defect created by the adhesions. The procedure not only involves the excision of the symblepharon but also the careful harvesting and placement of the graft to restore normal anatomical function and appearance. The inclusion of obtaining the graft in the procedure highlights the complexity and skill required in performing this surgery, ensuring that the repair is both functional and aesthetically pleasing.
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The procedure coded under CPT® 68335 is indicated for patients presenting with a symblepharon, which may result from various underlying conditions. The following are specific indications for performing this surgical repair:
The surgical procedure for CPT® 68335 involves several critical steps to ensure the successful repair of the symblepharon:
After the completion of the procedure, patients may require specific post-operative care to ensure optimal healing and recovery. This may include monitoring for any signs of infection, managing pain, and ensuring that the graft remains secure. Patients are typically advised on the importance of follow-up appointments to assess the healing process and the functionality of the repair. Additionally, instructions may be provided regarding activity restrictions and the use of any prescribed medications, such as topical antibiotics or anti-inflammatory agents, to support recovery and prevent complications.
| Short Descr | REVISE/GRAFT EYELID LINING | Medium Descr | RPR SYMBLEPHARON FR GRF CJNC/BUCCAL MUC MEMB | Long Descr | Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining 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 | 19 - Other therapeutic procedures on eyelids, conjunctiva, cornea |
| 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) | 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). | 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.) | E3 | Upper right, eyelid | 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). | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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.) | E1 | Upper left, eyelid | E2 | Lower left, eyelid | E4 | Lower right, eyelid | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service |
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| Pre-1990 | Added | Code added. |
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