Clinical Context
A Thirty-four-year-old male presents to the emergency department after blunt facial trauma from a motor vehicle collision. He reports decreased vision, severe eye pain, and visible laceration of the cornea with an irregular pupil. On ophthalmic exam there is a full-thickness corneal laceration with prolapse of intraocular tissue and concern for open-globe injury. The ophthalmology team performs urgent operative repair under general anesthesia in the operating room. The procedure includes primary closure of the corneal and/or scleral tear, inspection of the anterior chamber, repositioning or removal of prolapsed uveal tissue (iris or ciliary body), and layered wound closure. Postoperative care includes topical antibiotics, intraocular pressure monitoring, tetanus prophylaxis as indicated, and close outpatient follow-up for retina and intraocular infection surveillance.
Coding Specifications
| Modifier | Description | When to Use |
|---|
00 | No modifier provided (general placeholder) | Rarely used clinically; not typically appended — use specific modifiers instead |
| 22 | Increased procedural services | Use when the repair required substantially greater effort or complexity than usual
| 23 | Unusual anesthesia | Use when general anesthesia is administered for a procedure that is usually performed with local anesthesia
| 26 | Professional component | Use when billing only the physician (professional) component separate from technical services
| 50 | Bilateral procedure | Use when bilateral ocular repairs are performed and payer accepts bilateral modifier
| 52 | Reduced services | Use when the procedure is partially reduced or not completed as planned
| 53 | Discontinued procedure | Use when the procedure is terminated due to extenuating circumstances
| 62 | Two surgeons | Use when two surgeons from different specialties actively perform distinct portions of the procedure
| 63 | Procedure performed on infants less than 4 kg | Use when applicable for neonatal patients meeting weight criteria
| 78 | Unplanned return to OR for a related procedure during global period | Use when the patient returns to the operating room for revision related to the initial repair during the global period
| 79 | Unrelated procedure or service by the same physician during the postoperative period | Use when an unrelated procedure is performed during the global postoperative period
| 80 | Assistant surgeon | Use when an assistant surgeon actively assists during the procedure
| 81 | Minimum assistant surgeon | Use when a minimal assistance role is documented and allowed
| LT | Left side | Use to indicate the left eye
| RT | Right side | Use to indicate the right eye
| Taxonomy Code | Specialty | Notes |
|---|
| 207W00000X | Ophthalmology | Primary specialty that performs corneal and scleral laceration repairs |
| 2080P0005X | Ophthalmic Plastic and Reconstructive Surgery | Manages complex periocular and ocular surface reconstruction associated with globe trauma
| 207L00000X | Optometry | May provide triage and co-management but does not perform operative globe repair in most systems
| 2086S0128X | Pediatric Ophthalmology & Strabismus | Performs similar repairs in pediatric patients when indicated
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
S05.01XA | Contusion of conjunctiva and corneal abrasion without foreign body, initial encounter | Corneal surface trauma that may accompany or be distinguished from laceration injuries |
| S05.11XA | Penetration of cornea without foreign body, initial encounter | Directly describes penetrating corneal injury that necessitates repair
| S05.12XA | Penetration of cornea with foreign body, initial encounter | Corneal laceration with retained foreign body often requiring operative removal and repair
| S05.21XA | Penetration of sclera without foreign body, initial encounter | Scleral lacerations needing exploration and layered closure
| S05.22XA | Penetration of sclera with foreign body, initial encounter | Scleral laceration with retained intraocular foreign body; may require combined anterior and posterior procedures
| T15.90XA | Foreign body in unspecified eye, initial encounter | Use when a foreign body is present in the globe prompting repair and possible removal
| H16.239 | Corneal ulcer, unspecified eye | Secondary or coexisting corneal infection risk after traumatic laceration; important for postoperative management
| H59.89 | Other intraoperative and postprocedural complications and disorders of eye and adnexa | Applicable when documenting complications related to repair and subsequent care
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
65850 | Repair of recurrent retinal detachment with vitrectomy; complex | Performed when posterior-segment repair is required following open-globe injury or intraocular foreign body |
| 67036 | Vitrectomy, posterior segment; pars plana, mechanical vitrectomy (separate procedure) | May be performed during the same operative session if vitreous prolapse or posterior complications are present
| 67028 | Intravitreal injection of a pharmacologic agent | May be used postoperatively for intravitreal antibiotics or other agents when indicated
| 65778 | Graft of conjunctiva or cornea (lamellar keratoplasty) | May be required as a staged or concurrent procedure for extensive corneal tissue loss
| 65820 | Repair of traumatic iridodialysis or iris repair | Often performed concurrently to reposition or repair damaged iris tissue following globe trauma