New Guidance on Coding for Pterygium Excision With Graft

This article is from October 2012 and may contain outdated material.

How should you code for pterygium excisions? After a recent review of the relevant CPT codes and the valuation each one received from CMS, the Academy’s Health Policy Committee now recommends that when such an excision is performed with an amniotic membrane transplant (AMT) but without a conjunctival autograft, the only code submitted is 65426 Excision or transposition of pterygium; with graft. The rationale is that CPT code 65426 includes pterygium removal with any type of graft—whether conjunctival or amniotic, sutured or glued—and is the correct way to report the service.

When pterygium excision is performed with a conjunctival autograft, and a sutured AMT is performed, appropriate claims submission is CPT code 65426 Excision or transposition of pterygium; with graft and CPT code 65779 Placement of amniotic membrane on the ocular surface for wound healing; single layer, sutured. In these cases the surgeon has already done the work of CPT code 65426 when performing a pterygium excision and a conjunctival autograft. Then, in addition, the surgeon applies AMT, perhaps because the defect was too big to cover with conjunctiva alone. Performance of two grafts supports the billing of a second code for the AMT (65779 for sutured or 66999 for glued).

Excision Without Autograft

Here’s how to code for cases of pterygium excision without conjunctival autograft and with …

… AMT, single layer or multilayer, sutured. Use CPT code 65426.

MISTAKES TO AVOID: Combination use of CPT codes 65779 and 65426 is not considered appropriate because 65426 does not specify the type of graft. And because the AMT is the graft, it is not appropriate to bill CPT code 65420 Excision or transposition of pterygium; without graft.

… AMT, single layer or multilayer, glued. Use CPT code 65426.

MISTAKES TO AVOID: Combination use of CPT codes 66999 and 65426 is no longer considered appropriate because 65426 does not specify the type of graft. As explained above, it is not appropriate to bill CPT code 65420.

Excision With Autograft

Here’s how to code for cases of pterygium excision with conjunctival autograft and with …

… AMT, single layer or multilayered, sutured. Use CPT codes 65426 and 65779.

… AMT, single layer or multilayer, glued. Use CPT codes 65426 and 66999.

CODING TIP: CPT 2012 specifies the following: “For placement of amniotic membrane using tissue glue, use 66999.”