CCSD code C3960 – Pterygium excision

Key takeaways

CCSD code C3960 is the UK private-sector code for excision of pterygium, in Chapter 4 (Eye and orbital contents) of the CCSD schedule.

CCSD publishes codes and narratives but no fees, so insurers such as Bupa and AXA Health each price C3960 from their own schedules.

The excision technique does not change the code, but a graft or adjuvant radiotherapy line needs clearing with the insurer before you invoice it.

UK practices use WHO ICD-10, where pterygium is H11.0 with no laterality. ICD-10-CM splits it by eye: H11.001, H11.002, H11.003 and H11.009.

UK insurers expect pre-authorization before planned pterygium surgery, and the authorization number belongs on the C3960 invoice.

CCSD code C3960: Definition and clinical scope

CCSD code C3960 is the code for excision of pterygium in the CCSD Schedule of Procedures.

The Clinical Coding & Schedule Development (CCSD) Group maintains that schedule for UK private healthcare. Insurers such as Bupa, AXA Health, Freedom Health and National Friendly use it to identify procedures on invoices.

The official CCSD descriptor for C3960 is Excision of pterygium. It applies when an ophthalmologist surgically removes a pterygium from the conjunctiva and corneal surface. The descriptor names no technique, so bare sclera excision and graft-based repair share the same code.

The code sits in Chapter 4 of the procedural schedule, Eye and orbital contents, where every code begins with a C prefix. Insurer fee schedules, such as National Friendly’s, class C3960 as a Minor complexity procedure. Our CCSD code guides cover other procedures in the schedule in the same format.

CCSD publishes no fees. Its Technical Guide leaves complexity bands and reimbursement to each funder. The amount you invoice therefore comes from the patient’s insurer, never from the CCSD schedule itself.

What pterygium excision involves

A pterygium is a benign, fibrovascular growth of conjunctival tissue that spreads onto the cornea from the nasal or temporal limbus. Surgery is indicated when it threatens the visual axis, causes chronic irritation that conservative treatment has not settled, or grows quickly. Clearance before refractive surgery is another common reason for referral.

The main surgical approaches include:

• Bare sclera excision: The pterygium is removed and the scleral bed is left exposed. This is the simplest technique, but it carries a higher recurrence rate.
• Conjunctival autograft (CAG): Healthy conjunctiva from the superior bulbar surface is sutured or glued over the scleral bed. It markedly reduces recurrence and is the standard approach for most primary pterygia.
• Amniotic membrane transplant (AMT): Preserved amniotic membrane replaces the autograft, mainly when donor conjunctiva is limited or the pterygium has recurred.
• Mitomycin C (MMC): An antimetabolite applied to the scleral bed during surgery to reduce recurrence, often in recurrent or aggressive cases.

Anesthesia is usually topical or local, often a sub-Tenon block, for primary cases. General anesthesia is reserved for anxious patients or complex bilateral surgery. Most cases run as day surgery.

What C3960 includes and what it does not

CCSD aims for a single code to describe the whole procedure in most cases. It also lists unacceptable combinations against each code, which are pairs that should not appear on the same invoice. The Technical Guide treats those lists as guidelines, and each insurer decides what it pays.

The table below shows how the common parts of a pterygium operation relate to C3960. Where a line says to check with the insurer, confirm it before surgery rather than after a query.

Related CCSD codes near C3960

Several Chapter 4 codes cover other conjunctival procedures. Choosing one of them for a pterygium, or adding one without checking, is a common source of queries. The descriptors below match our guide to C3950 and published insurer schedules.

The CCSD Schedule itself needs a login to search, so confirm descriptors there or in the insurer’s schedule before invoicing. For how the schedule is organized and how Bupa applies it, see our UK CCSD guide.

ICD-10 diagnosis codes to pair with CCSD code C3960

Where an insurer or your billing system asks for a diagnosis, UK practices use the WHO edition of ICD-10. In that edition, pterygium is a single code, H11.0, with no laterality. Record the operated eye in the notes and on the pre-authorization, because the code will not carry it.

Software built on ICD-10-CM, the US edition, uses a more detailed set. There, H11.00 (unspecified pterygium of eye) is a parent code and not billable. The table lists the codes that are.

Use the most specific code the notes support. If the diagnosis, the operation note and the authorization name different eyes, expect the insurer to query the invoice.

Anesthesia and facility billing considerations

Pterygium excision is usually a day procedure under topical or local anesthesia. Each part of the episode is invoiced by the person or facility that provided it, and C3960 covers the surgeon’s procedure only.

• Local anesthesia given by the surgeon: Ask the insurer before invoicing it separately. C3960’s unacceptable combinations and the insurer’s rules decide whether a second line is paid.
• Anesthetist: A separate anesthetist invoices their own fee. Insurer schedules such as Freedom Health’s show a separate anesthetist fee for Chapter 4 codes.
• Hospital or day-surgery unit: The facility invoices operating room time, nursing and consumables itself. These charges sit outside the surgeon’s C3960 invoice.
• Both eyes: CCSD uses no modifiers, and C3960 carries no laterality. Ask the insurer how it wants bilateral surgery invoiced and which multiple-procedure reduction applies.

Pre-authorization requirements for UK private insurers

UK private medical insurers expect the patient to obtain pre-authorization before planned surgery. Bupa, AXA Health, Aviva and Vitality all ask members to contact them before treatment. An invoice without an authorization number is likely to be queried or rejected.

Requirements differ by insurer and policy. When the insurer asks the surgeon for supporting details, the request typically covers:

• Pterygium extent, including corneal encroachment toward the visual axis in millimeters
• Visual acuity, before and after conservative treatment
• Evidence that lubricants or anti-inflammatory drops have been tried without controlling symptoms
• The surgical indication, such as a threat to the visual axis, recurrent irritation or clearance before refractive surgery
• The diagnosis, ICD-10 H11.0 with the eye stated, or the ICD-10-CM code where your system uses it
• The proposed CCSD code, C3960, plus any additional code you plan to invoice

Most policies exclude cosmetic treatment, so record the functional reason for surgery. Confirm the authorization number in writing and keep it in the patient file. Quote it on the invoice with the consultant’s details and the date of surgery.

The diagram below traces the operated eye and the authorization number through the four documents an insurer may compare.

Documentation required for a successful C3960 claim

A complete clinical record supports a payable C3960 invoice. Insurers may request notes when they review eye surgery claims, especially where a graft line or both eyes appear. The pre-operative assessment and the operation note must together support each line.

Key documentation elements include:

• Pre-operative assessment: Pterygium extent in millimeters of corneal encroachment, the eye affected and visual acuity with and without correction
• Indication for surgery: The documented reason, with evidence that conservative options were considered
• Operation note: Technique used, adjuncts such as mitomycin C or fibrin glue, the eye operated on, duration and anesthesia type
• Diagnosis: ICD-10 H11.0, with the operated eye matching the notes and the authorization
• Insurer details: The patient’s insurer, membership number and pre-authorization number

In Pabau, the practice software we build, clinical records keep operation notes and pre-operative assessments in the patient file. Digital clinical forms can capture pterygium extent and technique in the same fields for every patient.

Common reasons C3960 claims are denied

Queries and rejections on C3960 usually trace back to a few recurring causes. Most are preventable before the invoice goes out.

Coding recurrent pterygium: Does C3960 still apply?

C3960 still applies to recurrent pterygium, because its descriptor does not separate primary from recurrent surgery. Recurrent cases are harder, though. The scleral bed may be scarred, tissue planes are disrupted and the risk of further recurrence is higher.

In WHO ICD-10, recurrent pterygium still codes to H11.0. ICD-10-CM has its own recurrent codes, H11.061 to H11.063 and H11.069. When requesting authorization for a recurrent case, include:

• Documentation of the original excision, including date, technique and outcome
• Evidence of recurrence, with extent and visual impact
• The planned technique, typically a conjunctival autograft or AMT, often with mitomycin C
• Why the more complex approach is clinically necessary

Mitomycin C is used more often in recurrent cases. Whether it can appear as a separate line depends on the insurer, so get written confirmation first. If the revision needs a further code, such as a graft, check its descriptor and unacceptable combinations in the current CCSD schedule.

How Pabau links C3960 claims to their pre-authorization

Many ophthalmology practices still keep authorization numbers in emails or spreadsheets and retype them onto each invoice. One missed number sends the claim back, and the team loses days reworking it.

Pabau’s claims management stores each insurer pre-authorization as a case. Attach the case when you book the surgery, and the authorization code follows the appointment through to the claim. A claim with no case attached is flagged before it goes out.

UK claims go out through Healthcode and Bupa, and the insurers you can reach come from Healthcode’s own payer list. Insurers outside Healthcode can still be invoiced as third parties. The claims dashboard tracks each claim from Pending to Paid, so an overdue C3960 invoice shows up without a manual chase.

Keep every C3960 claim tied to its authorization

Pabau stores each insurer pre-authorization as a case and sends private medical insurance claims through Healthcode, so C3960 invoices leave the practice complete.

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Conclusion

Choosing C3960 is the easy part of a pterygium claim. Claims stall on what surrounds the code. The usual culprits are a missing authorization number, an eye recorded differently across documents, or a bundled graft line.

Settle bundling and bilateral questions with the insurer when you book the surgery. That extra call takes minutes, while a queried invoice can take weeks to resolve.

Book a demo to see how Pabau links pre-authorizations to claims for UK private ophthalmology practices.

Continue your research

Need a broader CCSD reference? Our UK CCSD guide explains how the schedule is organized and how Bupa applies CCSD codes.

Giving radiotherapy after a pterygium excision? CCSD code C3950 covers radiotherapy to conjunctival lesion and when to ask the insurer before invoicing it.

Looking to reduce claim rework across your practice? Pabau’s claims management links pre-authorizations to claims and tracks each one from Pending to Paid.

Coding the same operation for a US payer? CPT code 65426 covers excision of pterygium with a graft under the US code set.

Frequently asked questions