How to bill CPT 65778?

To bill CPT 65778 (placement of an amniotic membrane on the ocular surface without sutures), report the procedure code along with the correct modifiers and supply rules based on your specific payer guidelines.

General Billing Rules

• Code definition: CPT 65778 covers the sutureless placement of an amniotic membrane (such as Prokera) on the eye.
• Global period: There is a zero-day global period for CPT 65778.
• Modifiers: Append the correct laterality modifier (-RT, -LT, or -50 for bilateral procedures) according to your payer's instructions. Use modifier -25 on an evaluation and management (E/M) code only if a significant, separately identifiable exam was performed on the same day.

Medicare vs. Commercial Payers

• Medicare: Bill only the procedure code 65778. The cost of the amniotic membrane supply is already bundled into the procedure payment, so do not bill HCPCS code V2790 separately.
• Commercial Payers: Many commercial insurance plans require you to bill the procedure code 65778 alongside the material code V2790 for the tissue supply. Always verify local commercial policies and check if prior authorization is necessary.

The direct price of a single amniotic membrane tissue graft ranges from $63 to $900, depending strictly on its size, configuration, and brand. However, the total cost for a patient undergoing a medical procedure involving an amniotic membrane transplant typically ranges between $1,300 and $2,000+ out of pocket, and can go much higher depending on the complexity of the surgery, provider fees, and clinic location.

Cost Breakdown

• Material/Supply Cost: Small, basic dental or small ocular membranes (e.g., 10x10mm) cost between $63 and $150. Larger or dual-layer specialized clinical membranes range from $200 to $900. Some complex, highly processed hospital-grade tissue formats can cost significantly more per square centimeter.
• In-Office Procedure Cost (Without Insurance): For standard sutureless placements—such as applying a PROKERA lens for severe dry eye syndrome—the total commercial clinic charge averages around $2,000 if paying completely out of pocket.
• Surgical Facility Fees: If the membrane must be surgically grafted or sutured in an operating room for advanced wound care or corneal reconstruction, hospital or facility fees can drive the total institutional costs to $3,000 to $10,000+.

Insurance and Reimbursement

For patients in the United States, health insurance and Medicare routinely cover amniotic membrane placement (using CPT code 65778 for sutureless eye applications) when it is deemed medically necessary to treat qualifying conditions like severe dry eye disease, corneal ulcers, chemical burns, or non-healing wounds. Under Medicare, the designated doctor's fee for the procedure is closely regulated, though the hospital or clinic facility fees are billed separately. Always verify coverage with your specific insurance carrier beforehand, as pre-authorization is usually required.

CPT code 65435 requires an eye modifier (RT or LT) to specify which eye was treated, and it may need an E/M modifier (-25) if billed with a separate same-day evaluation.

When to Use Modifiers with CPT 65435

• Laterality Modifiers (RT or LT): Always append modifier RT (right eye) or modifier LT (left eye) to indicate the exact location of the procedure. If performed on both eyes in separate sessions or per payer rules, bilateral modifiers may apply.
• Modifier 25: Add modifier 25 to a same-day Evaluation and Management (E/M) or eye visit code only if the provider performs a significant, separately identifiable service apart from the decision to perform the debridement. Do not append an E/M modifier if the exam was done solely to evaluate for the procedure itself.
• Modifier 59 / X{EPSU}: Generally not needed or allowed unless an unbundled, distinct minor procedure is performed on the same day that bypasses standard National Correct Coding Initiative (NCCI) edits, though 65435 has a 0-day global period.

The difference between CPT codes 65400 and 65435 comes down to the depth of the corneal tissue removed and the clinical purpose of the procedure.

CPT Code 65400

• Description: Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium.
• Depth: True superficial keratectomy going deeper than just the outer layer.
• Technique: Often involves a surgical blade (like a Beaver blade) to excise abnormal or thickened basement membrane and a diamond burr to polish Bowman's membrane.
• Purpose: Performed to remove an actual corneal lesion or abnormal tissue beyond the epithelium.

CPT Code 65435

• Description: Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage).
• Depth: Limited strictly to the outermost layer (the epithelium), even if a diamond burr or scraping instrument is used for the debridement.
• Technique: Superficial scraping or debridement using a spatula, curette, or burr.
• Purpose: Performed for epithelial debridement, recurrent corneal erosion, or removing surface debris like a rust ring.

The CPT code for a standard corneal debridement (removal of the corneal epithelium via abrasion or curettage) is 65435.

Overview of Code 65435

• Description: Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage).
• Common Uses: Treating recurrent corneal erosions, superficial corneal dystrophies, or removing corneal filaments.
• Global Period: It is categorized as a minor procedure with a 0-day global surgical period.

Important Coding Considerations

• Bandage Contact Lenses: The fitting and application of a bandage contact lens (such as CPT 92071) performed during or immediately after the debridement procedure are bundled into 65435 and cannot be billed separately.
• Chelating Agents: If the epithelial removal requires a chemical agent like EDTA (ethylenediaminetetraacetic acid), a different code (65436) applies.
• Deep Tissue Removal: If the procedure involves a true superficial keratectomy—excising abnormal tissue beyond just the outer epithelial layer using specialized blades—code 65400 may be required instead.