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Official Description

Canthotomy (separate procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Canthotomy is a surgical procedure primarily performed at the lateral canthus, which is the outer corner of the eye. This procedure is indicated to alleviate pressure and swelling that may occur in the eye, often as a result of trauma. The technique involves a series of steps that begin with the application of a hemostat to the skin at the lateral aspect of the eye. This action serves two purposes: it helps to achieve hemostasis, which is the cessation of bleeding, and it also marks the intended line of incision. Following this, the hemostat is released, and forceps are utilized to elevate the skin surrounding the lateral aspect of the eye, allowing for better access to the underlying structures. The incision is then made with scissors, starting at the lateral canthus and extending outward from the eye. In cases where the initial incision does not adequately relieve the pressure and swelling, the procedure may involve exposing and dividing the lateral canthus tendon. The incision is intentionally left open to facilitate the reduction of pressure and swelling in the affected area, promoting healing and recovery.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Canthotomy is performed for specific indications related to ocular trauma and associated complications. The following conditions may warrant this procedure:

  • Trauma to the Eye - Canthotomy is indicated in cases of significant eye trauma that leads to increased intraocular pressure or swelling.
  • Pressure Relief - The procedure is utilized to relieve pressure in the eye, which can occur due to hematoma formation or other traumatic injuries.
  • Swelling Management - Canthotomy is performed to address swelling around the eye that may compromise vision or ocular function.

2. Procedure

The canthotomy procedure involves several critical steps to ensure effective relief of pressure and swelling in the eye. The following outlines the procedural steps:

  • Step 1: Hemostasis and Incision Marking - The procedure begins with the application of a hemostat to the skin on the lateral aspect of the eye. This is maintained for 1-2 minutes to achieve hemostasis, which helps control bleeding and marks the line for the incision.
  • Step 2: Skin Elevation - After the hemostat is released, a forceps is used to gently elevate the skin around the lateral aspect of the eye. This step is crucial for providing access to the underlying tissues and structures that may require intervention.
  • Step 3: Making the Incision - Using scissors, the surgeon makes an incision that begins at the lateral canthus and extends laterally outward from the eye. This incision is designed to relieve the pressure and allow for further exploration if necessary.
  • Step 4: Division of the Lateral Canthus Tendon - If the initial incision does not adequately relieve the pressure and swelling, the procedure may require exposing and dividing the lateral canthus tendon. This step is performed to further alleviate the symptoms and facilitate healing.
  • Step 5: Open Incision - The incision is intentionally left open to allow for the reduction of pressure and swelling in the affected area. This open approach promotes drainage and healing as the body responds to the trauma.

3. Post-Procedure

After the canthotomy procedure, careful monitoring of the patient is essential to assess the effectiveness of the intervention. The open incision allows for drainage, and it is important to observe for any signs of infection or complications. Patients may experience some swelling and discomfort in the area, which should gradually subside as healing progresses. Follow-up care may include regular assessments to ensure that the pressure and swelling are adequately managed and that the eye is healing properly. Additional interventions may be necessary if complications arise or if the initial procedure does not achieve the desired outcome.

Short Descr CANTHOTOMY
Medium Descr CANTHOTOMY SEPARATE PROCEDURE
Long Descr Canthotomy (separate procedure)
Status Code Active Code
Global Days 010 - Minor Procedure
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) 1 - Statutory 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 19 - Other therapeutic procedures on eyelids, conjunctiva, cornea
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.
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.
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.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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.)
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.)
AG Primary physician
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
SG Ambulatory surgical center (asc) facility service
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
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
Date
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2025-01-01 Changed Short Description changed.
Pre-1990 Added Code added.
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