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The procedure described by CPT® Code 68400 involves the incision and drainage of the lacrimal gland, which is a critical component of the eye's tear production system. This procedure is typically indicated when there is an abscess or an accumulation of fluid within the lacrimal gland or lacrimal sac, which can lead to discomfort, swelling, and potential infection. The process begins with the cleansing of the upper eyelid to prepare the area for intervention. A local anesthetic may be administered to minimize discomfort during the procedure. Once the area is adequately prepared, the surgeon identifies the site of fluctuance, which indicates the presence of fluid accumulation. An incision is then made to allow for drainage of the fluid. If loculations, or pockets of fluid, are present, they are disrupted using both blunt and sharp dissection techniques to ensure complete drainage. Following the drainage, the area may be flushed with an antibiotic solution to reduce the risk of infection. Depending on the specific circumstances of the case, the incision may be left open to facilitate further drainage, or a drain may be placed, with the skin being closed around it to maintain the integrity of the area while allowing for continued drainage if necessary.
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The procedure described by CPT® Code 68400 is indicated for the treatment of conditions involving the lacrimal gland or lacrimal sac, specifically when there is an accumulation of fluid that may lead to complications. The following are the explicit indications for performing this procedure:
The procedure for CPT® Code 68400 involves several critical steps to ensure effective drainage of the lacrimal gland. The following procedural steps are outlined:
After the procedure, patients may require specific post-operative care to ensure proper healing and to monitor for any complications. It is important to follow up with the healthcare provider to assess the site of the incision and ensure that there are no signs of infection or other issues. Patients may be advised on how to care for the incision site, including keeping it clean and dry. Additionally, any prescribed medications, such as antibiotics, should be taken as directed to prevent infection. The expected recovery time may vary depending on the individual case, but patients should be informed about signs of complications that would necessitate immediate medical attention.
| Short Descr | I&D LACRIMAL GLAND | Medium Descr | INCISION&DRAINAGE LACRIMAL GLAND | Long Descr | Incision, drainage of lacrimal gland | 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 | 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). | 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. | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician | GZ | Item or service expected to be denied as not reasonable and necessary | 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 | 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 and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
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