CPT CODES

CPT Code 65426

CPT code 65426 is a medical billing code for the surgical removal of a lesion on the eye.

Table of Contents
What is CPT Code 65426
Does CPT 65426 Need a Modifier?
CPT Code 65426 Medicare Reimbursement
Are You Being Underpaid for 65426 CPT Code?
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What is CPT Code 65426

CPT code 65426 is designated for the surgical procedure involving the removal of a lesion from the cornea of the eye. This code is used specifically when the removal is performed by excision, which involves cutting out the lesion with a scalpel or another surgical instrument. This procedure is typically necessary when the lesion is causing vision impairment or has the potential for malignancy.

Does CPT 65426 Need a Modifier?

For the CPT code 65426, which pertains to the excision of a corneal lesion, several modifiers may be applicable depending on the specific circumstances of the procedure. Here is an ordered list of potential modifiers and the reasons for their use:

1. -RT (Right Side) and -LT (Left Side): These modifiers are used to indicate which eye underwent the procedure. Since the eyes are bilateral structures, specifying the side is crucial for accurate billing and medical records.

2. -50 (Bilateral Procedure): If the procedure is performed on both eyes during the same surgical session, this modifier should be used. It helps in notifying the payer that the procedure was bilateral, which can affect reimbursement.

3. -22 (Increased Procedural Services): This modifier is used when the work required to perform the surgery is substantially greater than typically required. Documentation must support the extra work and reason, such as increased complexity or patient-specific factors.

4. -52 (Reduced Services): If the procedure is partially reduced or eliminated at the physician's discretion, this modifier should be applied. It indicates that the service provided was less extensive than usually described by the CPT code.

5. -59 (Distinct Procedural Service): This modifier is used to indicate that the procedure was distinct or independent from other services performed on the same day. It is crucial for preventing the bundling of procedures and ensuring appropriate reimbursement.

6. -78 (Return to the Operating Room for a Related Procedure During the Postoperative Period): If the patient needs to return to the operating room for a related procedure during the recovery period, this modifier is necessary. It indicates that the subsequent procedure is related to the first but is a separate encounter.

7. -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): This modifier is used when a new procedure (unrelated to the initial procedure) is performed while the patient is still in the postoperative period.

Each of these modifiers addresses specific circumstances that might affect how the procedure is billed and reimbursed. Accurate modifier use is essential for compliance and proper revenue cycle management in healthcare.

CPT Code 65426 Medicare Reimbursement

CPT code 65426, which pertains to the excision of a corneal lesion, is generally reimbursed by Medicare. However, the specific amount of reimbursement can vary based on the Medicare Administrative Contractor (MAC) jurisdiction, geographic location, and the setting in which the procedure is performed (e.g., outpatient hospital, ambulatory surgery center, or physician's office).

To determine the exact reimbursement amount, it is advisable for healthcare providers to check with their local MAC or use the Medicare Physician Fee Schedule Look-Up Tool available on the Centers for Medicare & Medicaid Services (CMS) website. This tool provides detailed information about the reimbursement rates for specific procedures under Medicare Part B. Additionally, providers should ensure that the documentation supports the medical necessity of the procedure to facilitate appropriate reimbursement.

Are You Being Underpaid for 65426 CPT Code?

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