In today’s clinical conversations, we can’t talk about treating the cornea without discussing amniotic membranes as a clinical option. While the code for amniotic membranes for ocular use has gone through a few iterations as far as definition is concerned, it currently is defined as:

• 65778: Placement of amniotic membrane on the ocular surface; without sutures.

It is considered a surgical code and application, even though the definition indicates “without sutures.” This category follows a different set of rules when creating the medical record and coding for application and follow-up visits.

There are additional considerations to keep in mind. All amniotic membranes may not be created equally, as the CMS has noted in a recent Local Coverage Determination (LCD)¹:

“Amnion can be prepared for implantation a number of ways. Heat- or air-dried amniotic membrane loses some of its biologic properties and is not ideal for ocular surface rehabilitation.” 

However, “the cryopreservation method allows for greater retention of the membrane’s structural, physiological and biochemical properties responsible for its dramatic healing and easier handling intraoperatively.”

Covered Indications

Amniotic membrane transplant for ocular conditions is considered medically reasonable and necessary for the following indications:

• Failure of standard therapy for severe ophthalmological conditions demonstrated by ocular surface cell damage or failure and/or underlying inflammation, scarring or ulceration of the underlying stroma.
• Circumstances where there is a severe condition requiring acute treatment with amniotic membrane such as chemical, thermal or radiation injuries, or Stevens-Johnson syndrome or limbal stem cell failure.
• Band keratopathy after treatment with other therapy such as surgery, topical medications, bandage contact lens or patching.
• Bullous keratopathy associated with an epithelial defect.
• Scleral melting.
• Corneal ulcer following initiation of anti-infective therapy and demonstration of clinical response for the purpose of healing the persistent epithelial defect.
• Chemical burns of the ocular surface.
• Conjunctival defects after treatment with other therapy such as surgery or topical medications.
• Corneal melting.
• Limbal Stem Cell Deficiency.
• Recurrent Corneal Erosions after treatment failure with other therapy such as bandage contact lens, patching, and topical medications.

While I realize that using an amniotic membrane for dry eye is a commonplace occurrence, many carriers will not cover dry eye as a diagnosis, but will cover the corneal sequelae caused by moderate to severe dry eye.

Other Considerations

Coding for a minor surgical procedure is not difficult, but realize that, in accordance with minor surgical rules, an office visit (either 920XX or 992XX) is generally not separately billable when performed on the same date of service as CPT code 65778. Reimbursement for the 65778 code itself already includes compensation for the office visit related to the decision to perform this minor surgical procedure. So, it would be the rare occasion to append modifier -25 to an E/M office visit performed on the same day as the application of an amniotic membrane.

Make sure that your medical record contains an operative report that specifies the details of the procedure and discharge instructions for the patient.

The global period for 65778 is zero days, so the postoperative period expires at the end of the day the service was performed. All follow-up examinations beginning on the day after the procedure was performed are separately billable. Another notable characteristic of the code is:

Bilateral/unilateral status. As with many surgical codes, this is a bilateral 150% procedure, meaning if you perform it bilaterally on the same day, you will get 100% for the first procedure and 50% for the fellow eye.

While reimbursement looks enticing, don’t let it guide your clinical decisions. Having amniotic membranes as part of your treatment arsenal is a big boon to your practice. Establish appropriate and proper medical necessity for the procedure to ensure that you survive an audit.

Send your coding questions to [email protected].

Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.