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Excision of a lesion from the sclera, as described by CPT® Code 66130, involves the surgical removal of abnormal growths or lesions located on the sclera, which is the white outer coating of the eyeball. These lesions are typically benign and can manifest in various forms, including pingueculae, which are yellowish, slightly elevated growths commonly found in the area between the eyelids. Additionally, pigmented lesions may arise from melanocytes or non-melanocytes and can be either congenital or acquired. The removal of scleral lesions may be indicated for cosmetic reasons or if the lesions increase in size and cause discomfort to the patient. The procedure is performed under local anesthesia, utilizing a topical ophthalmic anesthetic to ensure patient comfort. The surgical site is prepared with an antibacterial solution to minimize the risk of infection. An eyelid speculum is then inserted to keep the eyelids open during the procedure, allowing for clear access to the lesion. Following the excision, there may be a need for tissue grafting to repair any surgical defect created by the removal of the lesion. To further enhance the outcome, a cytotoxic drug known as Mitomycin C may be applied briefly to the area to help reduce scarring before being flushed away, ensuring optimal healing and cosmetic results.
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Excision of a lesion from the sclera is indicated for several reasons, primarily focusing on the nature and impact of the lesions present. The following conditions may warrant this procedure:
The procedure for excising a scleral lesion involves several critical steps to ensure safety and effectiveness. Each step is outlined as follows:
After the excision of the scleral lesion, patients may require specific post-procedure care to ensure proper healing and minimize complications. It is essential to monitor the surgical site for any signs of infection or unusual changes. Patients are typically advised to avoid rubbing or putting pressure on the eye and may be prescribed antibiotic eye drops to prevent infection. Follow-up appointments are crucial to assess the healing process and to determine if any further treatment is necessary. Patients should also be informed about potential side effects, such as temporary discomfort or redness, which are common following the procedure.
| Short Descr | REMOVE EYE LESION | Medium Descr | EXCISION LESION SCLERA | Long Descr | Excision of lesion, sclera | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P4E - Eye procedure - other | MUE | 1 | CCS Clinical Classification | 20 - Other intraocular therapeutic procedures |
| LT | Left side (used to identify procedures performed on the left side of the body) | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |
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