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The procedure described by CPT® Code 67415 refers to the fine needle aspiration of orbital contents, a minimally invasive technique used to evaluate masses or lesions located within the orbit, which is the bony cavity that houses the eye. This procedure is particularly useful for obtaining cellular samples from suspicious growths or abnormalities without the need for more invasive surgical interventions. During the process, the eyelid covering the area of interest is first cleansed to reduce the risk of infection. To enhance patient comfort, local anesthetic eye drops or gel may be applied, numbing the area where the needle will be inserted. The physician applies firm pressure to stabilize the eye, ensuring accurate needle placement. The fine needle is then carefully inserted through the eyelid and directed into the mass or lesion. Once the needle is positioned correctly, the syringe plunger is retracted to create negative pressure, allowing for the aspiration of tissue or fluid from the lesion. The needle is manipulated back and forth within the targeted area to maximize the amount of aspirate collected. After sufficient material is obtained, the needle is withdrawn, and the aspirate is prepared on slides for further evaluation, which is reported separately. This procedure is essential for diagnosing various conditions affecting the orbital region, providing critical information for subsequent management and treatment decisions.
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The fine needle aspiration of orbital contents, as described by CPT® Code 67415, is indicated for the evaluation of various masses or lesions located within the orbit. The following conditions may warrant this procedure:
The procedure for fine needle aspiration of orbital contents involves several critical steps to ensure accurate sampling and patient safety. The following procedural steps are outlined:
After the fine needle aspiration of orbital contents, the patient may be monitored for any immediate complications, such as bleeding or discomfort. It is important to provide post-procedure care instructions, which may include avoiding rubbing the eye and monitoring for signs of infection. The prepared slides containing the aspirate will be sent for evaluation, and the results will guide further management and treatment decisions based on the findings. Patients may be advised to follow up with their healthcare provider to discuss the results and any necessary next steps.
| Short Descr | ASPIRATION ORBITAL CONTENTS | Medium Descr | FINE NEEDLE ASPIRATION ORBITAL CONTENTS | Long Descr | Fine needle aspiration of orbital contents | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P4E - Eye procedure - other | MUE | 1 | CCS Clinical Classification | 18 - Diagnostic procedures on eye |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | LT | Left side (used to identify procedures performed on the left side of the body) | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician | RT | Right side (used to identify procedures performed on the right side of the body) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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