Revenue Cycle Insider

Question: I have an operative note that lists the operation as “Keratectomy, right eye.” Below is a portion of the op note:

Procedure description: A drop of proparacaine followed by 2 drops of Betadine separated by 5 minutes were placed in the surgical eye. An eyelid speculum was placed in the surgical eye. The patient was positioned at the slit lamp. A Kimura spatula was used to remove the corneal epithelium. A #69 Beaver blade was used to excise the adherent areas of irregular thickened basement membrane and a diamond burr was used to polish Bowman membrane. The eyelid speculum was removed. A drop of Polytrim, prednisolone and ketorolac were placed in the surgical eye. An 8.4 BC bandage contact lens was placed in the surgical eye. A second drop of Polytrim, prednisolone and ketorolac were placed in the surgical eye. The patient tolerated the procedure well and left the minor procedure room in stable condition.

I’m having trouble determining the differences between 65435 and 65400. Could you help me assign the correct procedure code?

Michigan Subscriber

Answer: Choosing between 65435 (Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage)) and 65400 (Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium) comes down to the depth of tissue removed and the documentation of the procedure.

In your case, 65400 is appropriate for the procedure. You’ll use this code when the physician performs a true superficial keratectomy, which means the provider excises any abnormal corneal tissue beyond the epithelium. This procedure typically involves the use of a blade (like a Beaver blade), excision of thickened or irregular basement membrane, and using a diamond burr to polish the Bowman’s membrane — all of which occurred in the procedure you presented.

On the other hand, you’d assign 65435 when the physician removes the corneal epithelium, even if they use a diamond burr during the procedure. This is usually referred to as a superficial debridement or epithelial debridement.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC