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65420

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CPT 65420: Excision or transposition of pterygium; without graft

Code Description

  • Long Title: Excision or transposition of pterygium; without graft
  • Short Title: EXCISION PTERYGIUM W/O GRAFT
  • Explanation: This procedure involves the surgical removal (excision) or the surgical repositioning (transposition) of a pterygium, which is a non-cancerous, wing-shaped growth of the conjunctiva that extends onto the cornea. This specific code is used when the surgeon does not use a graft (such as an autologous conjunctival graft or amniotic membrane) to cover the bare sclera after excision.

Reimbursement & Work Details

  • wRVU: 5.48 (Work Relative Value Units)
  • Global Period: 090 Days (Major surgical procedure)
  • Assistant Payable: No (The use of an assistant surgeon is generally not supported for this procedure).

ICD-10-CM / Diagnosis Code(s)

Primary Diagnosis: H11.0- (Pterygium of eye) Note: This category requires 5th and 6th characters for laterality and type.

  • H11.001 - H11.003: Unspecified pterygium (Right, Left, Bilateral)
  • H11.011 - H11.013: Amyloid pterygium (Right, Left, Bilateral)
  • H11.021 - H11.023: Central pterygium (Right, Left, Bilateral)
  • H11.031 - H11.033: Peripheral pterygium, stationary (Right, Left, Bilateral)
  • H11.041 - H11.043: Peripheral pterygium, progressive (Right, Left, Bilateral)
  • H11.051 - H11.053: Recurrent pterygium (Right, Left, Bilateral) — High clinical relevance for recurrence cases.

HCC Information:

  • ICD-10 codes in the H11.0 range generally do not map to a Hierarchical Condition Category (HCC).

Bundling & NCCI Edits

Includes (Incidental/Bundled into 65420):

  • Local anesthesia (subconjunctival injections).
  • Standard surgical supplies and dressings.
  • Postoperative care within the 90-day global period.
  • Simple closure of the conjunctiva.

Exclusives / Mutually Exclusive (Cannot be billed with 65420):

  • 65426: Excision or transposition of pterygium; with graft. If a graft is performed, only 65426 is reported.
  • 65400: Excision of lesion, cornea (except pterygium).
  • 65780: Ocular surface reconstruction; amniotic membrane transplantation (This is bundled into 65426, but if performed without the intent of 65420’s “without graft” status, it may conflict).

Coding Tree & Hierarchy

  • Eye and Ocular Adnexa (65091-68899)
    • Eyeball (65091-65290)
      • Cornea (65400-65785)
        • Excision (65400-65426)
          • 65420: Pterygium excision, no graft.
          • 65426: Pterygium excision, with graft.

Typically performed in an Outpatient or ASC setting. If inpatient:

  • MS-DRG 124: Other Disorders of the Eye with MCC.
  • MS-DRG 125: Other Disorders of the Eye without MCC.

Coding Examples & Scenarios

Scenario 1: Simple Excision

  • Documentation: “Patient presents with a progressive pterygium on the right eye causing irritation and visual axis encroachment. The pterygium was dissected from the cornea and excised. The sclera was left bare to heal by secondary intention.”
  • Coding:
    • CPT: 65420-RT
    • ICD-10: H11.041 (Peripheral pterygium, progressive, right eye)

Scenario 2: Bilateral Procedure

  • Documentation: “Excision of stable pterygia on both the left and right eyes. No grafts used.”
  • Coding:
    • CPT: 65420-50 (or 65420-RT, 65420-LT depending on payer requirements).
    • ICD-10: H11.033 (Peripheral pterygium, stationary, bilateral)

Clinical Use Cases

  1. Visual Impairment: When the growth crosses the pupillary margin.
  2. Chronic Irritation: Severe redness, itching, or foreign body sensation unresponsive to conservative treatment.
  3. Induced Astigmatism: The growth pulls on the cornea, distorting vision.
  4. Restricted Motility: Large growths that prevent normal eye movement.

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