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65426

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CPT 65426: Excision or transposition of pterygium; with graft

Code Description

  • Long Title: Excision or transposition of pterygium; with graft
  • Short Title: EXCISION PTERYGIUM W/GRAFT
  • Explanation: This procedure involves the surgical removal (excision) or repositioning of a pterygium (a fleshy, non-cancerous growth of the conjunctiva that encroaches onto the cornea). Crucially, this code is utilized when the surgeon uses a graft to cover the bare scleral defect left by the excision. The graft can be a conjunctival autograft (tissue taken from another part of the patient’s own eye) or an amniotic membrane transplant (AMT).

Reimbursement & Work Details

  • wRVU: 6.05 (Work Relative Value Units)
  • Global Period: 090 Days (Major surgical procedure)
  • Assistant Payable: No (Medicare and most commercial payers do not allow an assistant surgeon for this procedure).

ICD-10-CM / Diagnosis Code(s)

Primary Diagnosis: H11.0- (Pterygium of eye) Note: This category requires 5th and 6th characters to specify 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) — Highly relevant, as grafts are specifically favored in recurrent cases to prevent future regrowth.

HCC Information:

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

Bundling & NCCI Edits

Includes (Incidental/Bundled into 65426):

  • Local anesthesia (e.g., retrobulbar or subconjunctival injections).
  • Harvesting and placement of the graft (whether conjunctival or amniotic membrane).
  • Standard surgical supplies, sutures, or tissue glue (e.g., Tisseel) used to secure the graft.
  • Routine postoperative care within the 90-day global period.

Exclusives / Mutually Exclusive (Cannot be billed with 65426):

  • 65420: Excision of pterygium; without graft. (Mutually exclusive; you cannot bill both a “with graft” and “without graft” code for the same lesion).
  • 65780, 65778, 65779: Ocular surface reconstruction or amniotic membrane placement. Major Compliance Note: CPT 65426 does not specify the type of graft. Because an amniotic membrane is considered a graft, you cannot bill an amniotic membrane placement code in addition to 65426 for the same pterygium excision. The membrane is bundled into 65426.

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.

While almost exclusively performed in an Outpatient/Ambulatory Surgery Center (ASC) setting, if performed inpatient, it maps to:

  • MS-DRG 124: Other Disorders of the Eye with MCC (Major Complication or Comorbidity).
  • MS-DRG 125: Other Disorders of the Eye without MCC.

Coding Examples & Scenarios

Scenario 1: Excision with Conjunctival Autograft

  • Documentation: “Patient has a progressive pterygium on the left eye. The pterygium was dissected and excised. A free conjunctival autograft was harvested from the superior bulbar conjunctiva of the same eye and secured over the bare sclera using fibrin tissue glue.”
  • Coding:
    • CPT: 65426-LT
    • ICD-10: H11.042 (Peripheral pterygium, progressive, left eye)
    • Explanation: The use of the autograft triggers 65426. The tissue glue is an included supply and not separately billable.

Scenario 2: Excision with Amniotic Membrane

  • Documentation: “Patient presents with a severe recurrent pterygium on the right eye. The pterygium was excised. Due to the size of the defect and history of recurrence, a sutured amniotic membrane transplant was placed over the excision site to facilitate healing and prevent regrowth.”
  • Coding:
    • CPT: 65426-RT
    • ICD-10: H11.051 (Recurrent pterygium, right eye)
    • Explanation: Even though an amniotic membrane was used, 65426 represents an excision “with graft”. Do not bill 65779 or 65780 alongside this, as it violates NCCI bundling rules.

Scenario 3: Double Pterygium on the Same Eye

  • Documentation: “Excision of a nasal pterygium and a temporal pterygium on the right eye, both utilizing conjunctival grafts.”
  • Coding:
    • CPT: 65426-RT (Only 1 unit)
    • Explanation: CPT 65426 has a Medically Unlikely Edit (MUE) of 1. Even if two separate pterygia are excised from the same eye, Medicare typically only pays for one unit per day. Modifiers like 59 or 51 are generally not successful for multiple pterygia on the same eye; appeals with operative notes demonstrating extraordinary work (modifier -22) are required if additional reimbursement is sought.

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