Summary & Overview

CPT 65426: Pterygium Excision or Transposition with Graft

CPT code 65426 defines surgical management of a pterygium that includes excision or transposition of the lesion combined with a graft. This ophthalmic procedure is performed to restore ocular surface integrity, improve vision, and relieve symptoms caused by pterygium growth. Nationally, the code matters for surgical ophthalmology billing, utilization tracking, and policy design for ocular surface procedures.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure, typical sites of service, and an outline of billing considerations. The publication summarizes common modifiers seen with this service, expected service line placement, and how this code aligns with related ophthalmic surgical codes.

The report provides benchmarks where available, highlights relevant policy updates affecting coverage and prior authorization practices, and clarifies coding boundaries to support accurate claim submission. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 65426pterygium excisionophthalmology surgeryocular surface graftambulatory surgical centeroutpatient surgerysurgical codingophthalmic proceduresprocedure coding

Billing Code Overview

CPT code 65426 describes excision or transposition of a pterygium with graft. This procedure involves removal or repositioning of the pterygium tissue on the ocular surface and performing a graft to improve patient comfort and vision.

Service type: Surgical ophthalmic procedure (pterygium excision with graft)
Typical site of service: Ambulatory surgical center or hospital outpatient department

Clinical & Coding Specifications

Clinical Context

A 54-year-old patient presents to an ophthalmology clinic with a symptomatic nasal pterygium encroaching on the cornea causing foreign-body sensation, tearing, intermittent blurred vision, and cosmetic concern. After topical anesthesia and periocular sedation as needed, the surgeon performs excision of the pterygium with mobilization/transposition of the fibrovascular tissue and placement of a conjunctival autograft (or amniotic membrane graft) to reduce recurrence. The procedure is typically performed in an outpatient ophthalmic surgical center or hospital ambulatory surgery unit under monitored anesthesia care or local anesthesia with sedation. Preoperative evaluation includes ocular surface assessment, visual acuity, slit-lamp biomicroscopy, and informed consent addressing recurrence risk and graft technique. Postoperative workflow includes topical antibiotic and steroid regimen, scheduled follow-up at day 1, week 1, and subsequent visits to monitor graft viability and healing, with documentation of laterality and any intraoperative complications.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the surgeon’s professional service separate from facility technical charges.
`50`

Taxonomy Code	Specialty	Notes
207W00000X	Ophthalmology	Corneal and external disease specialists commonly perform pterygium excision with grafting.
207WS0100X	Ocular Plastic Surgery (Ophthalmic Plastic & Reconstructive Surgery)	Surgeons with external ocular reconstructive expertise may perform complex grafting or conjunctival reconstruction.
207VP0800X	Cornea and External Disease	Providers focused on corneal surgery frequently manage recurrent or large pterygia and advanced graft techniques.
208100000X	Optometry	In some regions, optometrists with surgical privileges perform minor ocular surface procedures per local scope (where permitted).
207K00000X	Retina/Vitreous	Data not applicable as primary but may be involved if combined posterior segment procedures are performed.

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`65426`	Excision or transposition of pterygium with graft	Primary procedure: removal of pterygium with conjunctival autograft or other graft to reduce recurrence and restore ocular surface.
`65420`	Excision of pterygium, simple; without graft	Alternative/lesser procedure when excision is performed without grafting; may be performed for small, non-recurrent lesions.
`65435`	Excision of recurrent pterygium, complicated, with graft	Used for recurrent or complex pterygia requiring more extensive excision and grafting techniques.
`65778`	Conjunctival autograft for pterygium repair; single graft	Often used to report the graft harvest/placement component when documentation distinguishes graft procedure separate from excision (payer-specific).
`12001`	Simple repair of superficial wounds of face, ears, eyelids (2.5 cm or less)	May be reported if concurrent eyelid or periocular skin repairs are performed during the same operative session (payer rules vary).

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