Wiki How would you code this procedure? 65435 or 65400. The provider and I go back n forth with these two codes. Does anyone have any further insight?

[kjfetts]

Professional side - Payer is Medicare Part B - MAC - WPS

POSTOPERATIVE DIAGNOSIS: Epithelial basement membrane dystrophy, right eye.
OPERATION PERFORMED: Keratectomy, right eye.
ANESTHESIA: Topical Proparacaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 0 ml.
DESCRIPTION OF THE CASE IN DETAIL: After discussing the risks, benefits and alternatives of
keratectomy, consent was signed, and the patient was escorted into the minor procedure room. 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. A 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.

 

[Edmundo]

Hi @kjfetts - It's a pleasure!

This is a very common gray area, especially with epithelial basement membrane dystrophy (EBMD) cases.

Both 65435 and 65400 can come into play, and the correct code really depends on the depth of tissue removal and how the procedure is documented.

65435 is appropriate when the procedure is limited to removal of the corneal epithelium (abrasion, curettage), even if a diamond burr is used. This is typically considered a superficial debridement.

65400 is more appropriate when the provider performs a true superficial keratectomy, meaning there is excision of abnormal corneal tissue beyond just the epithelium, often involving:

• Use of a blade (e.g., Beaver blade)
• Removal of irregular or thickened basement membrane
• Polishing of Bowman’s layer with a diamond burr as part of the keratectomy

In your case, if the documentation supports excision of abnormal tissue (not just epithelial removal), then 65400 would be more appropriate.

Encourage the provider to document explicitly:

“Superficial keratectomy performed”

“Excision of irregular basement membrane/corneal tissue”

Include indication/medical necessity (e.g., recurrent erosions, visual disturbance, failed conservative treatment)

Avoid vague wording like “debridement” if more extensive work was done

Best,

Edmundo Gonzalez, CPC, CRCR, COPC, OCS