Most of the 2004 ophthalmology-related CPT changes pertain to oculoplastic surgery, including an overhaul of the descriptors for blepharoplasty. Let's look at some of the key revisions.

Re-defining blepharoplasty
In the past, "blepharoplasty" described any eyelid surgery. More recently, the terminology changed to help distinguish between various types of eyelid surgeries. While they were all once lumped under the heading of blepharoplasty, there is no association between the integumentary repair of eyelids (orbital fat prolapse or redundant skin) and the ophthalmic repair of eyelids (ectropion or entropion).

These changes have finally filtered into the descriptors in the integumentary and ophthalmology sections of the CPT book and should help reduce confusion. The ophthalmic codes have been revised to eliminate blepharoplasty from the descriptors and instead emphasize the intent of the procedure to repair ectropion or entropion. In coding terms, blepharoplasty is now synonymous with reducing orbital fat prolapse and redundant skin around the orbit.

Here are some examples of ophthalmic codes that no longer contain blepharoplasty in the descriptor:

• 67916. Repair of ectropion; excision tarsal wedge
• 67917. Repair of ectropion; extensive (for example, tarsal strip operations)
• 67923. Repair of entropion; excision tarsal wedge
• 67924. Repair of entropion; extensive (tarsal strip or capsulopalpebral fascia repairs operation).

Procedures for blepharoplasty should be coded with 15820, 15821, 15822 and 15823. Your coders can make the distinction by matching the code descriptor to the operative report.

The following clinical information must be documented in the medical record for blepharoplasty: identification of the surgical site(s) for each eyelid surgically treated (upper left, upper right, lower left, lower right) the surgeon's diagnosis (blepharochalasia, ectropion, entropion or lagophthalmos, for example) for each eyelid treated; the fraction of eyelid margin surgically treated (one-fourth of the lid margin, for example) and the surgical technique used for each repair (see "Matching Technique to Code" on page 22).

New transplantation codes
CPT codes 65780 through 65782 and 68371 represent transplantation of new tissue to the cornea to treat severe corneal surface disease. Corneal epithelial disease generally heals without difficulty, but may be disrupted by chemical injuries, toxic medications, mechanical insults, xerosis, trauma or sensory deprivation. Be sure to include the diagnosis indicating medical necessity. These are the descriptors:

• 65780. Ocular surface reconstruction; amniotic membrane transplantation
• 65781. Ocular surface reconstruction; limbal stem cell allograft (cadaveric or living donor)
• 65782. Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft)
• 68371. Harvesting conjunctival allograft, living donor.

How can you direct your billing staff to the correct code? These codes are defined first by the transplant materials used, either amniotic membranes or stem cells derived from donor conjunctiva (allograft) or from the patient's opposite eye (autograft). If the allograft is from a living donor, the surgeon attaches the graft to the perilimbal area to produce epithelial stem cells, which he'll transplant into the corneal surface. Code 68371 describes harvesting of the graft from the donor's conjunctiva.

Amniotic membranes act like a biological bandage to facilitate natural healing, while the stem cells promote corneal epithelization. Ocular surface reconstruction with limbal stem cell transplantation involves corneal-bed dissection and dissection of conjunctiva and sclera beyond the limbus.

Amniotic membrane and limbal stem cell transplants treat the following: corneal pannus and/or superficial corneal scarring, persistent corneal epithelial defects, corneal perforation, neurotrophic keratitis, persistent corneal epithelial defects, bullous keratopathy, corneal thinning, corneal ulcer, chemical burns of the ocular surface, Stevens-Johnson syndrome and erythema multiform. Make sure an appropriate diagnosis accompanies the operative report.