CPT Code: 65778  Region: 37

States covered:  General guidelines if your state does not have a local coverage determination

Title:  Placement of Amniotic Membrane on the Ocular Surface; Without Sutures.

Category
Minor Surgical Procedure

Description
Human amniotic membrane allografts are tissue-based products used as a biological corneal bandage to promote healing of the ocular surface.

This Medicare carrier does not have a local coverage determination (LCD) for the placement of an amniotic membrane on the ocular surface; without sutures.  The policy presented is to serve as a sample and is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.



Biological Corneal Bandage

  • The allograft is placed on the patient’s cornea as a temporary dressing to treat ocular surface disease
  • As it degrades, the allograft serves as a long-term drug delivery vehicle that releases bioactive components and signaling molecules that target the eye and the brain by stimulating the patient’s immune system

Amniotic membrane placement may be indicated in the treatment of ocular surface disease in any of the following circumstances:

  • Medical management fails
  • Medical management is not tolerated
  • Medical management is contraindicated

Amniotic membrane transplant for ocular conditions may be 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
  • Limbal stem cell failure
  • Band keratopathy
  • Bullous keratopathy
  • Corneal ulcer
  • Chemical or thermal burns of the ocular surface
  • Conjunctival degenerations and defects
  • Corneal melting

ICD-10 Diagnosis Codes

ICD-10 CodesDescription
H04.131 Lacrimal cyst, right lacrimal gland
H04.132 Lacrimal cyst, left lacrimal gland
H04.133 Lacrimal cyst, bilateral lacrimal glands
H04.139 Lacrimal cyst, unspecified lacrimal gland
H15.89 Other disorders of sclera
H15.90 Unspecified disorder of sclera
H16.001 Unspecified corneal ulcer, right eye
H16.002 Unspecified corneal ulcer, left eye
H16.003 Unspecified corneal ulcer, bilateral
H16.009 Unspecified corneal ulcer, unspecified eye
H16.011 Central corneal ulcer, right eye
H16.012 Central corneal ulcer, left eye
H16.013 Central corneal ulcer, bilateral
H16.019 Central corneal ulcer, unspecified eye
H16.021 Ring corneal ulcer, right eye
H16.022 Ring corneal ulcer, left eye
H16.023 Ring corneal ulcer, bilateral
H16.029 Ring corneal ulcer, unspecified eye
H16.031 Corneal ulcer with hypopyon, right eye
H16.032 Corneal ulcer with hypopyon, left eye
H16.033 Corneal ulcer with hypopyon, bilateral
H16.039 Corneal ulcer with hypopyon, unspecified eye
H16.041 Marginal corneal ulcer, right eye
H16.042 Marginal corneal ulcer, left eye
H16.043 Marginal corneal ulcer, bilateral
H16.049 Marginal corneal ulcer, unspecified eye
H16.051 Mooren's corneal ulcer, right eye
H16.052 Mooren's corneal ulcer, left eye
H16.053 Mooren's corneal ulcer, bilateral
H16.059 Mooren's corneal ulcer, unspecified eye
H16.061 Mycotic corneal ulcer, right eye
H16.062 Mycotic corneal ulcer, left eye
H16.063 Mycotic corneal ulcer, bilateral
H16.069 Mycotic corneal ulcer, unspecified eye
H16.071 Perforated corneal ulcer, right eye
H16.072 Perforated corneal ulcer, left eye
H16.073 Perforated corneal ulcer, bilateral
H16.079 Perforated corneal ulcer, unspecified eye
H16.101 Unspecified superficial keratitis, right eye
H16.102 Unspecified superficial keratitis, left eye
H16.103 Unspecified superficial keratitis, bilateral
H16.109 Unspecified superficial keratitis, unspecified eye
H16.111 Macular keratitis, right eye
H16.112 Macular keratitis, left eye
H16.113 Macular keratitis, bilateral
H16.119 Macular keratitis, unspecified eye
H16.121 Filamentary keratitis, right eye
H16.122 Filamentary keratitis, left eye
H16.123 Filamentary keratitis, bilateral
H16.129 Filamentary keratitis, unspecified eye
H16.131 Photokeratitis, right eye
H16.132 Photokeratitis, left eye
H16.133 Photokeratitis, bilateral
H16.139 Photokeratitis, unspecified eye
H16.141 Punctate keratitis, right eye
H16.142 Punctate keratitis, left eye
H16.143 Punctate keratitis, bilateral
H16.149 Punctate keratitis, unspecified eye
H16.201 Unspecified keratoconjunctivitis, right eye
H16.202 Unspecified keratoconjunctivitis, left eye
H16.203 Unspecified keratoconjunctivitis, bilateral
H16.209 Unspecified keratoconjunctivitis, unspecified eye
H16.211 Exposure keratoconjunctivitis, right eye
H16.212 Exposure keratoconjunctivitis, left eye
H16.213 Exposure keratoconjunctivitis, bilateral
H16.219 Exposure keratoconjunctivitis, unspecified eye
H16.221 Keratoconjunct sicca, not specified as Sjogren's, right eye
H16.222 Keratoconjunct sicca, not specified as Sjogren's, left eye
H16.223 Keratoconjunct sicca, not specified as Sjogren's, bilateral
H16.229 Keratoconjunct sicca, not specified as Sjogren's, unsp eye
H16.231 Neurotrophic keratoconjunctivitis, right eye
H16.232 Neurotrophic keratoconjunctivitis, left eye
H16.233 Neurotrophic keratoconjunctivitis, bilateral
H16.239 Neurotrophic keratoconjunctivitis, unspecified eye
H16.241 Ophthalmia nodosa, right eye
H16.242 Ophthalmia nodosa, left eye
H16.243 Ophthalmia nodosa, bilateral
H16.249 Ophthalmia nodosa, unspecified eye
H16.251 Phlyctenular keratoconjunctivitis, right eye
H16.252 Phlyctenular keratoconjunctivitis, left eye
H16.253 Phlyctenular keratoconjunctivitis, bilateral
H16.259 Phlyctenular keratoconjunctivitis, unspecified eye
H16.261 Vernal keratoconjunct, w limbar and corneal involv, r eye
H16.262 Vernal keratoconjunct, w limbar and corneal involv, left eye
H16.263 Vernal keratoconjunct, w limbar and corneal involv, bi
H16.269 Vernal keratoconjunct, w limbar and corneal involv, unsp eye
H16.291 Other keratoconjunctivitis, right eye
H16.292 Other keratoconjunctivitis, left eye
H16.293 Other keratoconjunctivitis, bilateral
H16.299 Other keratoconjunctivitis, unspecified eye
H16.301 Unspecified interstitial keratitis, right eye
H16.302 Unspecified interstitial keratitis, left eye
H16.303 Unspecified interstitial keratitis, bilateral
H16.309 Unspecified interstitial keratitis, unspecified eye
H16.311 Corneal abscess, right eye
H16.312 Corneal abscess, left eye
H16.313 Corneal abscess, bilateral
H16.319 Corneal abscess, unspecified eye
H16.321 Diffuse interstitial keratitis, right eye
H16.322 Diffuse interstitial keratitis, left eye
H16.323 Diffuse interstitial keratitis, bilateral
H16.329 Diffuse interstitial keratitis, unspecified eye
H16.331 Sclerosing keratitis, right eye
H16.332 Sclerosing keratitis, left eye
H16.333 Sclerosing keratitis, bilateral
H16.339 Sclerosing keratitis, unspecified eye
H16.391 Other interstitial and deep keratitis, right eye
H16.392 Other interstitial and deep keratitis, left eye
H16.393 Other interstitial and deep keratitis, bilateral
H16.399 Other interstitial and deep keratitis, unspecified eye
H16.401 Unspecified corneal neovascularization, right eye
H16.402 Unspecified corneal neovascularization, left eye
H16.403 Unspecified corneal neovascularization, bilateral
H16.409 Unspecified corneal neovascularization, unspecified eye
H16.411 Ghost vessels (corneal), right eye
H16.412 Ghost vessels (corneal), left eye
H16.413 Ghost vessels (corneal), bilateral
H16.419 Ghost vessels (corneal), unspecified eye
H16.421 Pannus (corneal), right eye
H16.422 Pannus (corneal), left eye
H16.423 Pannus (corneal), bilateral
H16.429 Pannus (corneal), unspecified eye
H16.431 Localized vascularization of cornea, right eye
H16.432 Localized vascularization of cornea, left eye
H16.433 Localized vascularization of cornea, bilateral
H16.439 Localized vascularization of cornea, unspecified eye
H16.441 Deep vascularization of cornea, right eye
H16.442 Deep vascularization of cornea, left eye
H16.443 Deep vascularization of cornea, bilateral
H16.449 Deep vascularization of cornea, unspecified eye
H16.8 Other keratitis
H16.9 Unspecified keratitis
H18.10 Bullous keratopathy, unspecified eye
H18.11 Bullous keratopathy, right eye
H18.12 Bullous keratopathy, left eye
H18.13 Bullous keratopathy, bilateral
H18.421 Band keratopathy, right eye
H18.422 Band keratopathy, left eye
H18.423 Band keratopathy, bilateral
H18.429 Band keratopathy, unspecified eye
H18.831 Recurrent erosion of cornea, right eye
H18.832 Recurrent erosion of cornea, left eye
H18.833 Recurrent erosion of cornea, bilateral
H18.839 Recurrent erosion of cornea, unspecified eye
H18.891 Other specified disorders of cornea, right eye
H18.892 Other specified disorders of cornea, left eye
H18.893 Other specified disorders of cornea, bilateral
H18.899 Other specified disorders of cornea, unspecified eye
L51.0 Nonbullous erythema multiforme
L51.1 Stevens-Johnson syndrome
L51.3 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome
L51.9 Erythema multiforme, unspecified
T26.00XA Burn of unspecified eyelid and periocular area, init encntr
T26.00XD Burn of unspecified eyelid and periocular area, subs encntr
T26.00XS Burn of unspecified eyelid and periocular area, sequela
T26.01XA Burn of right eyelid and periocular area, initial encounter
T26.01XD Burn of right eyelid and periocular area, subs encntr
T26.01XS Burn of right eyelid and periocular area, sequela
T26.02XA Burn of left eyelid and periocular area, initial encounter
T26.02XD Burn of left eyelid and periocular area, subs encntr
T26.02XS Burn of left eyelid and periocular area, sequela
T26.10XA Burn of cornea and conjunctival sac, unsp eye, init encntr
T26.10XD Burn of cornea and conjunctival sac, unsp eye, subs encntr
T26.10XS Burn of cornea and conjunctival sac, unsp eye, sequela
T26.11XA Burn of cornea and conjunctival sac, right eye, init encntr
T26.11XD Burn of cornea and conjunctival sac, right eye, subs encntr
T26.11XS Burn of cornea and conjunctival sac, right eye, sequela
T26.12XA Burn of cornea and conjunctival sac, left eye, init encntr
T26.12XD Burn of cornea and conjunctival sac, left eye, subs encntr
T26.12XS Burn of cornea and conjunctival sac, left eye, sequela
T26.20XA Burn w resulting rupture and dest of unsp eyeball, init
T26.20XD Burn w resulting rupture and dest of unsp eyeball, subs
T26.20XS Burn w resulting rupture and dest of unsp eyeball, sequela
T26.21XA Burn w resulting rupture and dest of right eyeball, init
T26.21XD Burn w resulting rupture and dest of right eyeball, subs
T26.21XS Burn w resulting rupture and dest of right eyeball, sequela
T26.22XA Burn w resulting rupture and dest of left eyeball, init
T26.22XD Burn w resulting rupture and dest of left eyeball, subs
T26.22XS Burn w resulting rupture and dest of left eyeball, sequela
T26.30XA Burns of oth parts of unsp eye and adnexa, init encntr
T26.30XD Burns of oth parts of unsp eye and adnexa, subs encntr
T26.30XS Burns of oth parts of unspecified eye and adnexa, sequela
T26.31XA Burns of oth parts of right eye and adnexa, init encntr
T26.31XD Burns of oth parts of right eye and adnexa, subs encntr
T26.31XS Burns of oth parts of right eye and adnexa, sequela
T26.32XA Burns of oth parts of left eye and adnexa, init encntr
T26.32XD Burns of oth parts of left eye and adnexa, subs encntr
T26.32XS Burns of oth parts of left eye and adnexa, sequela
T26.40XA Burn of unsp eye and adnexa, part unspecified, init encntr
T26.40XD Burn of unsp eye and adnexa, part unspecified, subs encntr
T26.40XS Burn of unsp eye and adnexa, part unspecified, sequela
T26.41XA Burn of right eye and adnexa, part unspecified, init encntr
T26.41XD Burn of right eye and adnexa, part unspecified, subs encntr
T26.41XS Burn of right eye and adnexa, part unspecified, sequela
T26.42XA Burn of left eye and adnexa, part unspecified, init encntr
T26.42XD Burn of left eye and adnexa, part unspecified, subs encntr
T26.42XS Burn of left eye and adnexa, part unspecified, sequela
T26.50XA Corrosion of unsp eyelid and periocular area, init encntr
T26.50XD Corrosion of unsp eyelid and periocular area, subs encntr
T26.50XS Corrosion of unspecified eyelid and periocular area, sequela
T26.51XA Corrosion of right eyelid and periocular area, init encntr
T26.51XD Corrosion of right eyelid and periocular area, subs encntr
T26.51XS Corrosion of right eyelid and periocular area, sequela
T26.52XA Corrosion of left eyelid and periocular area, init encntr
T26.52XD Corrosion of left eyelid and periocular area, subs encntr
T26.52XS Corrosion of left eyelid and periocular area, sequela
T26.60XA Corrosion of cornea and conjunctival sac, unsp eye, init
T26.60XD Corrosion of cornea and conjunctival sac, unsp eye, subs
T26.60XS Corrosion of cornea and conjunctival sac, unsp eye, sequela
T26.61XA Corrosion of cornea and conjunctival sac, right eye, init
T26.61XD Corrosion of cornea and conjunctival sac, right eye, subs
T26.61XS Corrosion of cornea and conjunctival sac, right eye, sequela
T26.62XA Corrosion of cornea and conjunctival sac, left eye, init
T26.62XD Corrosion of cornea and conjunctival sac, left eye, subs
T26.62XS Corrosion of cornea and conjunctival sac, left eye, sequela
T26.70XA Corrosion w resulting rupture and dest of unsp eyeball, init
T26.70XD Corrosion w resulting rupture and dest of unsp eyeball, subs
T26.70XS Corros w resulting rupture and dest of unsp eyeball, sequela
T26.71XA Corros w resulting rupture and dest of right eyeball, init
T26.71XD Corros w resulting rupture and dest of right eyeball, subs
T26.71XS Corros w rslt rupture and dest of right eyeball, sequela
T26.72XA Corrosion w resulting rupture and dest of left eyeball, init
T26.72XD Corrosion w resulting rupture and dest of left eyeball, subs
T26.72XS Corros w resulting rupture and dest of left eyeball, sequela
T26.80XA Corrosions of oth parts of unsp eye and adnexa, init encntr
T26.80XD Corrosions of oth parts of unsp eye and adnexa, subs encntr
T26.80XS Corrosions of oth parts of unsp eye and adnexa, sequela
T26.81XA Corrosions of oth parts of right eye and adnexa, init encntr
T26.81XD Corrosions of oth parts of right eye and adnexa, subs encntr
T26.81XS Corrosions of oth parts of right eye and adnexa, sequela
T26.82XA Corrosions of oth parts of left eye and adnexa, init encntr
T26.82XD Corrosions of oth parts of left eye and adnexa, subs encntr
T26.82XS Corrosions of oth parts of left eye and adnexa, sequela
T26.90XA Corrosion of unsp eye and adnexa, part unsp, init encntr
T26.90XD Corrosion of unsp eye and adnexa, part unsp, subs encntr
T26.90XS Corrosion of unsp eye and adnexa, part unspecified, sequela
T26.91XA Corrosion of right eye and adnexa, part unsp, init encntr
T26.91XD Corrosion of right eye and adnexa, part unsp, subs encntr
T26.91XS Corrosion of right eye and adnexa, part unspecified, sequela
T26.92XA Corrosion of left eye and adnexa, part unsp, init encntr
T26.92XD Corrosion of left eye and adnexa, part unsp, subs encntr
T26.92XS Corrosion of left eye and adnexa, part unspecified, sequela


All coverage criteria should be clearly documented in the patient’s medical record and made available to Medicare upon request.

The patient’s medical record should contain documentation that fully supports the medical necessity for amniotic membrane placement as covered by Medicare.  This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.

Report an amniotic membrane placement using CPT code 65778.

ProKera is a Class II medical device comprised of a cryopreserved amniotic membrane graft fastened to a thermoplastic ring-set.  The cell activity in the tissue has been inactivated to eliminate the possibility of graft rejection while retaining the natural biologic properties.

  • ProKera is intended for use in eyes in which ocular surface cells have been damaged, or underlying stroma is inflamed or scarred.  Acting as a self retaining biological bandage, ProKera effectively treats superficial corneal surface diseases by reducing pain, suppressing inflammation, promoting epithelial healing, and avoiding haze.
  • ProKera is inserted between the eyeball and the eyelid to maintain space in the orbital cavity and to prevent closure or adhesions.  Insertion of the conformer also enables application of the amniotic membrane to the ocular surface without the need for sutures.
  • ProKera is for single and prescription use only

Medicare covers the placement of an amniotic membrane when medically necessary.  However, they do not cover the cost of the supply of ProKera separately.  HCPCS code V2790, amniotic membrane for surgical reconstruction per procedure, is no longer eligible for discrete Medicare payment in any setting.  Reimbursement for the supply is included with payment for the procedure.

This Medicare carrier has no utilization guidelines for amniotic membrane placement.  It is expected that these services would be performed as indicated by current medical literature and/or current standards of optometric/ophthalmic practice.

In the absence of specific utilization guidelines, eye doctors should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of optometric/ophthalmic practice.