Summary & Overview

CPT 65410: Corneal Biopsy and Tissue Sampling

CPT code 65410 represents a corneal biopsy: the removal of suspicious corneal tissue for laboratory analysis to diagnose corneal diseases. This code captures a focused diagnostic ophthalmic procedure used when surface or stromal corneal lesions require histopathologic evaluation. Nationally, accurate coding for corneal biopsy affects clinical documentation, pathology billing, and appropriate tracking of ocular diagnostic services.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for 65410, typical sites of service, and common billing considerations. The publication covers expected benchmarks and coverage patterns, relevant coding relationships, and policy-related issues that influence claims submission and payment in a national context.

The material outlines how 65410 fits into ophthalmic diagnostic workflows, clarifies what the code represents for clinical and administrative teams, and highlights areas where coding accuracy and documentation support appropriate laboratory processing and reimbursement. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare65410CPTcorneal biopsyophthalmologydiagnostic proceduretissue samplingpathologyambulatory surgeryclinic

Billing Code Overview

CPT code 65410 describes a corneal biopsy procedure in which the provider takes samples of suspicious tissue from the cornea for histopathologic analysis. The specimen is submitted to a laboratory for diagnostic evaluation to determine the presence or nature of corneal disease.

Service type: Diagnostic tissue sampling (corneal biopsy)
Typical site of service: Ophthalmology clinic, ambulatory surgical center, or hospital outpatient department where corneal procedures and specimen submission to a laboratory are performed.

Clinical & Coding Specifications

Clinical Context

A patient presents to an ophthalmology clinic with a persistent, progressively enlarging corneal lesion that is irregular, elevated, or non-healing despite topical therapy. Symptoms include vision change, ocular irritation, focal corneal opacity, or suspected neoplasm. The provider performs slit-lamp examination with topical anesthesia and collects a corneal biopsy (superficial or deep as indicated) using a trephine, scalpel, or spatula. The specimen is placed in appropriate medium and submitted to a pathology laboratory for histopathologic and, if indicated, microbiologic or molecular analysis. Typical site of service is an ophthalmology outpatient clinic, ambulatory surgical center (ASC), or minor procedure room within a hospital ophthalmology service. The workflow includes informed consent, topical anesthesia, lesion sampling, specimen labeling and documentation, and forwarding the specimen with a requisition for diagnostic testing. Post-procedure care instructions and follow-up for results and further management are arranged.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the physician's interpretation/professional portion if technical component billed separately.
`TC`

Taxonomy Code	Specialty	Notes
`207RN0400X`	Ophthalmology	Corneal biopsy commonly performed by ophthalmologists with cornea/anterior segment expertise.
`207RP1001X`	Ophthalmic Plastic & Reconstructive Surgery	May perform if lesion involves periocular/corneal interface requiring specialized approach.
`207RR0500X`	Pediatric Ophthalmology	Pediatric corneal biopsies when performed in children.
`2080S0002X`	Optometry (Therapeutic)	Some therapeutic optometrists may assist in diagnosis but typically do not perform corneal biopsy; listed for referral context.
`363L00000X`	Pathology	Pathologists receive and interpret corneal biopsy specimens; technical and professional components apply.

ICD-10 Code	Description	Clinical Relevance
`H16.233`	Interstitial keratitis, bilateral	Used when biopsy is performed for suspected interstitial keratitis to identify etiology.
`H16.013`	Corneal ulcer, central, right eye	Corneal biopsy may be needed when non-healing or atypical ulcer requires tissue diagnosis.
`D03.9`	Melanoma in situ, unspecified	If suspicious pigmented corneal or limbal lesion suggests neoplasm, biopsy is indicated.
`H16.221`	Pannus of cornea, right eye	Biopsy may be performed when pannus tissue is atypical or refractory to therapy.
`H16.49`	Other corneal involvement in other diseases classified elsewhere	Used when corneal pathology needs tissue diagnosis related to systemic disease.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`65435`	Biopsy of eyelid, including margin, when performed	Performed when corneal lesion extends to or involves eyelid margin; may be done in the same session.
`92002`	Ophthalmological services; diagnostic, new patient, intermediate, with initiation of diagnostic and treatment program (office or other outpatient visit for the evaluation and management of a new patient)	Initial evaluation and decision to perform corneal biopsy often documented under an E/M visit for a new patient.
`92012`	Ophthalmological services; intermediate, established patient	Follow-up or established patient evaluation related to corneal disease prior to biopsy.
`88305`	Level IV surgical pathology, gross and microscopic examination	Common pathology code for submitted corneal biopsy specimen interpretation and report.
`87116`	Culture, pathogenic organisms; fungal, from corneal scraping or biopsy	If infectious keratitis is suspected, microbiologic culture codes may be added for laboratory analysis of corneal specimens.
`67840`	Excision of lesion of conjunctiva, simple; single lesion	If adjacent conjunctival lesion is excised in addition to corneal biopsy, this code may be reported.

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