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Scleral reinforcement is a surgical procedure aimed at addressing high myopia, a condition characterized by severe nearsightedness that can lead to complications such as damage to the macula. This procedure is performed as a separate intervention and involves the use of a graft to provide additional support to the weakened sclera, which is the white outer layer of the eyeball. The procedure begins with the application of local anesthesia to ensure patient comfort. A lid speculum is utilized to hold the eyelids open, allowing the surgeon to access the eye. The conjunctiva, a thin membrane covering the eye, along with Tenon's capsule, is incised approximately 6 mm from the corneal limbus, which is the border between the cornea and the sclera. The lateral, superior, and inferior recti muscles, which control eye movement, are carefully separated using a strabismus hook to facilitate access to the posterior aspect of the sclera. In cases where the sclera is reinforced without a graft, as described in CPT® Code 67250, the procedure involves creating an indentation in the posterior sclera. However, in CPT® Code 67255, a graft is employed to bolster the weakened area. The thinned region of the sclera is oversewn with a graft, typically an allograft from a donor, which is sutured to the healthier anterior sclera. This reinforcement helps to prevent further damage to the eye and supports the structural integrity of the sclera. After the graft is secured, the separated muscles are repaired, and the conjunctiva and Tenon's capsule are closed, completing the procedure.
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The scleral reinforcement procedure is indicated for patients suffering from high myopia, which can lead to significant ocular complications. The primary goal of this procedure is to prevent damage to the macula, a critical area of the retina responsible for central vision. The following conditions may warrant the performance of this procedure:
The scleral reinforcement procedure involves several critical steps to ensure effective treatment of high myopia. Each step is designed to carefully access and reinforce the sclera to prevent further ocular damage.
Post-procedure care is essential for optimal recovery following scleral reinforcement. Patients may be monitored for any signs of complications, such as infection or graft rejection. It is important to follow up with the healthcare provider for regular assessments of the eye's healing process. Patients may also be advised on activity restrictions and the use of prescribed medications, such as anti-inflammatory or antibiotic eye drops, to promote healing and prevent infection. The expected recovery time can vary, and patients should be informed about the signs of potential complications that warrant immediate medical attention.
| Short Descr | REINFORCE/GRAFT EYE WALL | Medium Descr | SCLERAL REINFORCEMENT SPX W/GRAFT | Long Descr | Scleral reinforcement (separate procedure); with graft | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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) | 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. | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | 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.) | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 55 | Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | E2 | Lower left, eyelid | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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