CAM 90307

Phototherapeutic Keratectomy

Category:Surgery   Last Reviewed:November 2019
Department(s):Medical Affairs   Next Review:November 2999
Original Date:November 1998    

Description:
Phototherapeutic keratectomy involves the use of the excimer laser to treat visual impairment or irritative symptoms relating to diseases of the anterior cornea by sequentially ablating uniformly thin layers of corneal tissue. Phototherapeutic keratectomy may be performed in the office setting using topical anesthesia. Phototherapeutic keratectomy must be distinguished from photorefractive keratectomy, which involves the use of the excimer laser to correct refractive errors of the eye (i.e., myopia, astigmatism, hyperopia and presbyopia). Photorefractive keratectomy is addressed in a separate policy, No. 90302.

Essentially, phototherapeutic keratectomy (PTK) functions by removing anterior stromal opacities or eliminating elevated corneal lesions while maintaining a smooth corneal surface. Complications of PTK include refractive errors, most commonly hyperopia, corneal scarring and glare. The U.S. Food and Drug Administration (FDA) labeling for the excimer laser identifies the following ophthalmologic therapeutic indications:

  • Superficial corneal dystrophies (including granular, lattice and Reis-Buckler's dystrophies)
  • Epithelial basement membrane dystrophy, irregular corneal surfaces (secondary to Salzmann's degeneration, keratoconus nodules or other irregular surfaces)
  • Corneal scars and opacities (i.e., post-traumatic, post-surgical, post-infectious and secondary to pathology).

Although not included in the FDA labeling, there has been interest in PTK as a treatment of recurrent corneal erosions in patients who have not responded to conservative therapy with patching, cycloplegia, topical antibiotics and lubricants.

When PTK is used to remove only the epithelial surface of the cornea, the alternative technology is mechanical superficial keratectomy, i.e., corneal scraping. When PTK is used to remove deeper layers of the cornea, i.e., extending into Bowman's layer, competing technologies include lamellar keratoplasty. In addition, candidates for PTK should have exhausted medical approaches. For example, recurrent corneal erosions can be treated conservatively with lubricants, patching, bandage contact lenses or anterior stromal punctures, while keratoconus can be treated with rigid contact lenses to correct the astigmatism.

Policy:

  • Phototherapeutic keratectomy may be considered MEDICALLY NECESSARY when used as an alternative to a lamellar keratoplasty in the treatment of visual impairment or irritative symptoms related to corneal scars, opacities or dystrophies extending beyond the epithelial layer.
  • Phototherapeutic keratectomy is considered NOT MEDICALLY NECESSARY when used as an alternative to a superficial mechanical keratectomy in treating patients with superficial corneal dystrophy, epithelial membrane dystrophy and irregular corneal surfaces due to Salzmann's nodular degeneration or keratoconus nodules.
  • INVESTIGATIONAL applications of phototherapeutic keratectomy include, but are not limited to, treatment of recurrent corneal erosions and infectious keratitis. 

Policy Guidelines:
There is no specific CPT code for PTK. CPT code 65400 (excision of lesion, cornea [keratectomy, lamellar, partial]) may be used. Superficial mechanical keratectomy may be coded by 65435-65436 (removal of corneal epithelium). CPT code 65710 describes a lamellar keratoplasty. There is a HCPCS code, S0812, that is specific for this procedure.
 

The following ICD-9 and ICD-10 codes describe superficial corneal lesions; PTK for these conditions would be considered NOT MEDICALLY NECESSARY.  

371.51 Juvenile epithelial corneal dystrophy
371.52 Other anterior corneal dystrophy
371.53 Granular corneal dystrophy
371.54 Lattice corneal dystrophy
371.46 Nodular degeneration of cornea (i.e., Salzmann's nodular dystrophy)
371.6 Keratoconus code range 

ICD-10-CM
H1852 Epithelial (juvenile) corneal dystrophy
H1859 Other hereditary corneal dystrophies
H1853 Granular corneal dystrophy
H1854 Lattice corneal dystrophy
H18459 Nodular corneal degeneration, unspecified eye
H18609 Keratoconus, unspecified, unspecified eye
H18619 Keratoconus, stable, unspecified eye
H18629 Keratoconus, unstable, unspecified eye 

The following ICD-9 and ICD-10 codes describe corneal scars and opacities and nonepithelial lesions; PTK for these conditions may be considered MEDICALLY NECESSARY.  

371.0 Corneal scar and opacities code range
371.56 Stromal corneal dystrophy 

ICD-10-CM
H17.00-H17.9
H18.00-H18.069 

The following ICD-9 and ICD-10 codes describe recurrent corneal erosions and infectious keratitis, and PTK for these conditions is considered INVESTIGATIONAL.  

371.42 Recurrent corneal erosions
017.3 Tuberculosis of the eye
053.21 Herpes zoster keratoconjunctivitis
054.40-054.49 Ophthalmologic herpes simplex code range
055.71 Measles keratoconjunctivitis
077.1 Epidemic keratoconjunctivitis
090.3 Syphilitic interstitial keratitis
370.44 Keratitis or keratoconjunctivitis in exanthema 

ICD-10-CM

H18839 Recurrent erosion of cornea, unspecified eye
A1850 Tuberculous episcleritis
A1851 Tuberculous keratitis
A1852 Tuberculous chorioretinitis
A1853 Tuberculous iridocyclitis
A1854 Other tuberculosis of eye
A1859 Other tuberculosis of eye
B0233 Zoster keratitis
B0050 Herpesviral ocular disease, unspecified
B0059 Other herpesviral disease of eye
B0052 Herpesviral keratitis
B0051 Herpesviral iridocyclitis
B0059 Other herpesviral disease of eye
B0581 Measles keratitis and keratoconjunctivitis
B300 Keratoconjunctivitis due to adenovirus
A5031 Late congenital syphilitic interstitial keratitis
H16299 Other keratoconjunctivitis, unspecified eye  

Benefit Application
BlueCard®/National Account Issues
It is anticipated that PTK may be routinely used as an alternative to superficial mechanical keratectomy, which, according to the above policy, would be considered not medically necessary. Therefore, plans may want to consider actively managing coverage eligibility for PTK, either through precertification or retrospective physician profiling. In the latter approach, retrospective review may be targeted to those physicians or facilities that perform a high volume of PTK procedures. The coverage policy regarding treatment of superficial corneal lesions is based on the lack of data demonstrating that PTK provides additional health benefits compared to the standard treatment of superficial mechanical keratectomy. Therefore, plans may want to consider whether additional reimbursement for PTK compared to superficial mechanical keratectomy is warranted.

Rationale
No controlled clinical study has directly compared PTK with other forms of treatment, including superficial keratectomy (used to treat superficial lesions) or lamellar keratoplasty (used to treat deeper lesions) or anterior stromal puncture (used to treat recurrent corneal erosions). The FDA approval was based on data from uncontrolled trials of patients with a variety of corneal pathologies. For example, Summit Technology presented data on 398 eyes, including 103 eyes with dystrophy (25.9 percent), 64 eyes with recurrent erosion (16.1 percent) and 231 eyes with scars, opacities or other irregular surfaces (58 percent). (1) Outcomes included best-corrected visual acuity and/or decrease in irritative symptoms, such as pain and discomfort. Among cases undergoing PTK to increase comfort, 88.5 percent were considered successes at 1 year. Among those with visual impairment, 63.4 percent were considered successes. The most common adverse effect was corneal scarring and glare, occurring in 13.7 percent and 12.2 percent of cases, respectively. The results of this trial have also been summarized by Maloney and colleagues. (2) Superficial mechanical keratectomy is regarded as a minimally invasive, safe and effective procedure to remove the superficial layer of the cornea. While PTK offers a more precise and elegant method of epithelial removal, no controlled studies have demonstrated that this technological superiority results in an improved patient health benefit. The precision of PTK may be most significant when deeper corneal lesions involving Bowman's layer are present. In this situation, PTK presents a minimally invasive alternative to lamellar keratoplasty.

There are inadequate data regarding the effectiveness of PTK in treating recurrent corneal erosions and infectious keratitis.

2005 Update
A literature review performed for the period of 2003 through November 2004 did not identify any published articles that would prompt reconsideration of the above policy. Therefore, the policy statement is unchanged.

References:

  1. Summit Technology, Inc., Summary of Safety and Receptiveness Data, ExciMed UV200LA or SVS Apex (formerly the OmniMed) Excimer Laser System for Phototherapeutic Keratectomy (PTK). Waltham, MA: Summit Technology, Inc. 1995.
  2. Maloney RK, Thompson, V, Ghiselli G et al. A prospective multicenter trial of excimer laser phototherapeutic keratectomy for corneal vision loss. The Summit Phototherapeutic Keratectomy Study Group. Am J Ophthalmol 1996; 122(2):149-60.
  3. Autrata R, et al. Phototherapeutic keratectomy in children: 5-year results. J Cataract Refract Surg 2004 Sep;30(9): 1909-16.
  4. Das S, et al. Excimer laser phototherapeutic keratectomy for grandular and lattice corneal dystrophy: a comparative study. J Refract Surg 2005 Nov-Dec; 21(6): 727-31.

Coding Section 

Codes Number Description
CPT   No specific code; see Policy Guidelines
ICD-9 Procedure 11.41 Mechanical removal of corneal epithelium
  11.49 Other removal or destruction of corneal lesion (keratectomy)
  11.59 Other repair of cornea
  11.61-11.62 Lemellar keratoplasty, code range
  16.93 Excision of lesion of eye, unspecified structure
ICD-9 Diagnosis 371.00-371.05 Corneal scars and opacities code range
  371.56 Other stromal corneal dystrophies
HCPCS S0812 Phototherapeutic keratectomy (PTK)
ICD-10-CM (effective 10/01/13) H17.00-H17.9 Corneal scars and opacities; code range
  H18.00-H18.069 Other disorders of cornea; code range
ICD-10-PCS (effective 10/01/13)    ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this procedure. If the procedure is performed inpatient, one of the following codes might be used.
  08Q8XZZ, 08Q9XZZ Surgical, eye, excision, cornea, external, code by body part (right or left) 
  0BQ00ZZ, 08B03ZZ, 08B0XZZ, 08B10ZZ, 08B13ZZ, 08B1XZZ,   Surgical, eye, excision, eye, code by body part (right or left) and approach (open, percutaneous or external)
  08B8XZZ, 08B9XZZ Surgical eye, excision, cornea, external, code by body part (right or Left) 
  08N8XZZ, 08N9XZZ  Surgical, eye, release, cornea, external, code by body part (right or left) 
  08Q8XZZ, 08Q9XZZ Surgical, eye, repair, cornea, external, code by body part (right or left) 
  08R8X7Z, 08R9X7Z, 08R8XKZ, 08R9XKZ   Surgical, eye, replacement, cornea, external, code by body part (right or left) and qualifier (autologous tissue substitute or nonautologous tissue substitute)
  08U8X7Z, 08U9X7Z, 08U8XKZ, 08U9XKZ Surgical, eye supplement, cornea, percutaneous, autologous tissue substitute, code by body part (right or left) and qualifier (autologous tissue substitute or nonautologous tissue substitute) 
 Type of Service Vision   
 Place of Service Outpatient   

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

Policy to remain active, but will not undergo scheduled review after 2015.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2013 Forward     

11/20/2019 

Annual review, no change to policy intent 

11/27/2018 

Annual review, no change to policy intent. 

11/15/2017 

Annual review, no change to policy intent 

11/01/2016 

Annual review, no change to policy intent 

11/04/2015 

Annual review, no change to policy intent. Updating guidelines to include ICD-10 coding. 

11/06/2014 

Annual review, no change to policy intent. Added coding, updated policy guidelines. 

10/16/2013

Updated Description, added Benefit Application and Rationale.


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