APR 19, 2016
Appropriate Billing for Double Pterygium
Question: When the patient has a double pterygium, is it appropriate to submit CPT code 65426 Excision of pterygium; with graft with 2 units and LT modifier to Medicare Part B?
Answer: This procedure is typically paid per eye, not per pterygium. However, since there are two separate incisions/procedures per eye, you may try billing the second procedure with modifier -XS Separate structure to Medicare Part B. If this was a commercial payer, modifier -59 would be appropriate.
You will need to include the locations in box 19. Remember that the payer may request the operative report and may or may not choose to pay for the second procedure.