Wiki Excision or transpostion of pterygium with graft code 65426

[bvance]

I have a claim for 65426 that was done on the left eye one was located on the left nasal side and the second was located on the left temporal side. I billed claim

65426/LT noting left Nasal
65426/51LT noting left Temporal

The payor denied the second procedure stating can only be done once in a lifetime so was already reimbursed with primary claim.

Please advise me if modifier 59LT would be correct for the second procedure. If anyone has any information or reference that will help me try and get the second procedure paid I would appreciate your help.

Thanks,

Becky

 

[lcathey@smsc.org]

We have a similar situation and was wondering about the 59 or 51 modifier. Any updates? Thanks!!

 

[mzkandyd]

Because this was the same anatomical site, there would be just the one code of 65426. However, if the op note states this was done via subconjunctival injection (most of them are) you would also add 68200 w/LT modifier. There is no second procedure because you are still on the LT eye. You could possibly add 22 modifier for increased services if they indeed have documentation to support the temporal and nasal side of the eye but please don't quote me on this because I do not have the operative note in front of me.

Here is information from the AMA regarding this procedure:

A pterygium is a fleshy, wedge of the bulbar conjunctiva covering a portion of the medial cornea. The physician excises the pterygium with a blade and forceps or scleral scissors. The edges of the pterygium are undermined following a superficial incision in the clear cornea. Forceps retract the freed pterygium and it is excised as gentle pressure pulls it away from the corneal tissue and across the limbus and sclera. The physician applies sutures to the sclera and conjunctiva as needed. Often, no graft or tissue rearrangement is needed (e.g., 65420). However, the physician may transpose the pterygium with normal conjunctival tissue to move it out of the field of vision in what is sometimes called McReynold's operation, or may make a circumcorneal incision and use a conjunctival flap to repair the pterygium site (e.g., 65426). A topical antibiotic and a pressure patch may be applied in either procedure.

I hope this helps!